Healthcare Provider Details

I. General information

NPI: 1699170787
Provider Name (Legal Business Name): MARY THERESA PALOVCAK DNP CRNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/31/2014
Last Update Date: 05/18/2026
Certification Date: 05/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

225 E CITY AVE STE 10
BALA CYNWYD PA
19004-1724
US

IV. Provider business mailing address

225 E CITY AVE STE 10
BALA CYNWYD PA
19004-1724
US

V. Phone/Fax

Practice location:
  • Phone: 215-503-8300
  • Fax:
Mailing address:
  • Phone: 215-503-8300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number26NJ00923500
License Number StateNJ
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberSP014263
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: