MEDICARE: NANCY ANN WALCZAK

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	224Z00000X	Occupational Therapy Assistant	3474	NM

General Provider Information

NPI Number	:	1811489958
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NANCY ANN WALCZAK

Provider Business Mailing Address
First Line	:	4338 CALLE AMARILLA
Second Line	:
City	:	LAS CRUCES
State	:	NM
Zip	:	88011-1822
Country	:	US
Telephone Number	:	575-202-0657
Fax Number	:

Provider Business Practice Location Address
First Line	:	1591 E LOHMAN AVE
Second Line	:
City	:	LAS CRUCES
State	:	NM
Zip	:	88001-3185
Country	:	US
Telephone Number	:	575-650-4444
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/05/2018
Last Update Date	:	06/05/2018

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