Provider Demographics
NPI:1881576247
Name:WALDREP, MARY KATHRYN (CRNP)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:KATHRYN
Last Name:WALDREP
Suffix:
Gender:X
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 PARK ST
Mailing Address - Street 2:
Mailing Address - City:HONESDALE
Mailing Address - State:PA
Mailing Address - Zip Code:18431-2051
Mailing Address - Country:US
Mailing Address - Phone:352-299-3055
Mailing Address - Fax:
Practice Address - Street 1:201 PARK ST
Practice Address - Street 2:
Practice Address - City:HONESDALE
Practice Address - State:PA
Practice Address - Zip Code:18431-2051
Practice Address - Country:US
Practice Address - Phone:352-299-3055
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-07-24
Last Update Date:2025-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP033089363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily