Basic Information
| Provider Information | |||||||||
| NPI: | 1689665952 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WIELICZKO | ||||||||
| FirstName: | KATHY | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | MSN, CPNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6 GREENHILL CT | ||||||||
| Address2: | |||||||||
| City: | MARLTON | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 080535379 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8567976591 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1ST FLOOR WOOD CENTER | ||||||||
| Address2: | 34TH & CIVIC CENTER BLVD | ||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 19104 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2155903440 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/04/2005 | ||||||||
| LastUpdateDate: | 08/14/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0200X | SP059690 | PA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics | 363LP0200X | 26NR09657400 | NJ | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics |
No ID Information.