Provider Demographics
NPI:1992288716
Name:WALSH, MARY BROOKE (FNP)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:BROOKE
Last Name:WALSH
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:
Other - Last Name:PIWINSKI
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:100 SAN PABLO TOWNE CENTER
Mailing Address - Street 2:#A
Mailing Address - City:SAN PABLO
Mailing Address - State:CA
Mailing Address - Zip Code:94505
Mailing Address - Country:US
Mailing Address - Phone:510-237-2802
Mailing Address - Fax:
Practice Address - Street 1:100 SAN PABLO TOWNE CENTER
Practice Address - Street 2:#A
Practice Address - City:SAN PABLO
Practice Address - State:CA
Practice Address - Zip Code:94505
Practice Address - Country:US
Practice Address - Phone:510-237-2802
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-07
Last Update Date:2021-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY343492363LF0000X
CA95014926363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily