Provider Demographics
NPI:1104811140
Name:MULLEN-WALSH, MARY (CRNP)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:MULLEN-WALSH
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:
Other - Last Name:WALSH
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:5 MORGAN HWY
Mailing Address - Street 2:SUITE 4
Mailing Address - City:SCRANTON
Mailing Address - State:PA
Mailing Address - Zip Code:18508-2641
Mailing Address - Country:US
Mailing Address - Phone:570-344-3788
Mailing Address - Fax:570-969-9280
Practice Address - Street 1:5 MORGAN HWY
Practice Address - Street 2:SUITE 4
Practice Address - City:SCRANTON
Practice Address - State:PA
Practice Address - Zip Code:18508-2641
Practice Address - Country:US
Practice Address - Phone:570-344-3788
Practice Address - Fax:570-969-9280
Is Sole Proprietor?:No
Enumeration Date:2005-09-15
Last Update Date:2020-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAVP005831B363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA103062761-0001Medicaid
PAP00293834OtherRAILROAD MEDICARE
PA027924OtherBLUE CARE
PA50076570OtherCAPITAL BLUE CROSS
PAS81889Medicare UPIN
PA103062761-0001Medicaid