Provider Demographics
NPI:1316711229
Name:DEWALD, MARY PATRICIA (APRN, RN, NP, CNS)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:PATRICIA
Last Name:DEWALD
Suffix:
Gender:F
Credentials:APRN, RN, NP, CNS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1218 LODGEPOLE DR
Mailing Address - Street 2:
Mailing Address - City:EVERGREEN
Mailing Address - State:CO
Mailing Address - Zip Code:80439-4604
Mailing Address - Country:US
Mailing Address - Phone:303-674-9355
Mailing Address - Fax:
Practice Address - Street 1:1218 LODGEPOLE DR
Practice Address - Street 2:
Practice Address - City:EVERGREEN
Practice Address - State:CO
Practice Address - Zip Code:80439-4604
Practice Address - Country:US
Practice Address - Phone:303-674-9355
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-11-10
Last Update Date:2023-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0003059363LW0102X, 364S00000X
374J00000X
CO85121163WC0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC0400XNursing Service ProvidersRegistered NurseCase Management
No363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
No364S00000XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse Specialist
No374J00000XNursing Service Related ProvidersDoula