1386049492 NPI number — KATHLEEN MARY NIEZGODA RN, MSN, CPNP, PMHS

Table of content: KATHLEEN MARY NIEZGODA RN, MSN, CPNP, PMHS (NPI 1386049492)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1386049492 NPI number — KATHLEEN MARY NIEZGODA RN, MSN, CPNP, PMHS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
NIEZGODA
Provider First Name:
KATHLEEN
Provider Middle Name:
MARY
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
RN, MSN, CPNP, PMHS
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1386049492
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/30/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2500 W LAYTON AVE
Provider Second Line Business Mailing Address:
SUITE 30
Provider Business Mailing Address City Name:
MILWAUKEE
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
53221-5420
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
414-269-5336
Provider Business Mailing Address Fax Number:
414-269-5437

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2500 W LAYTON AVE
Provider Second Line Business Practice Location Address:
SUITE 30
Provider Business Practice Location Address City Name:
MILWAUKEE
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53221-5420
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
414-269-5336
Provider Business Practice Location Address Fax Number:
414-269-5437
Provider Enumeration Date:
10/31/2014

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LP0200X , with the licence number:  5744-33 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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