Healthcare Provider Details

I. General information

NPI: 1326077637
Provider Name (Legal Business Name): STACY KOWALCZYK CRNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/30/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

339 W SPRING ST SUITE 102
TITUSVILLE PA
16354-1655
US

IV. Provider business mailing address

12053 CAMPBELL RD
TITUSVILLE PA
16354-5621
US

V. Phone/Fax

Practice location:
  • Phone: 814-827-9675
  • Fax:
Mailing address:
  • Phone: 814-827-8829
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberTP005917B
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: