Healthcare Provider Details

I. General information

NPI: 1700829314
Provider Name (Legal Business Name): MARY AGNES OSTICK CRNP
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 06/13/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 LANCASTER AVE VILLAVNOA UNIVERSITY
VILLANOVA PA
19085-1603
US

IV. Provider business mailing address

412 CHERRY LN
HAVERTOWN PA
19083-1619
US

V. Phone/Fax

Practice location:
  • Phone: 610-519-4070
  • Fax: 610-519-4047
Mailing address:
  • Phone: 610-446-4736
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number363LF0000X
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: