1457633497 NPI number — MRS. THERESA GLORIA KACZMAREK RN

Table of content: MRS. THERESA GLORIA KACZMAREK RN (NPI 1457633497)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1457633497 NPI number — MRS. THERESA GLORIA KACZMAREK RN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KACZMAREK
Provider First Name:
THERESA
Provider Middle Name:
GLORIA
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
RN
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
KRUEGER
Provider Other First Name:
THERESA
Provider Other Middle Name:
GLORIA
Provider Other Name Prefix Text:
MISS
Provider Other Name Suffix Text:
Provider Other Credential Text:
RN
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1457633497
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/15/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
N15W30165 TIMBER BROOK RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PEWAUKEE
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
53072-6100
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
262-844-0879
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
N15W30165 TIMBER BROOK RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PEWAUKEE
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53072-6100
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
262-844-0879
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/15/2011

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: 163W00000X , with the licence number:  117264-030 , 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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