Provider Demographics
NPI:1689665952
Name:WIELICZKO, KATHY L (MSN, CPNP)
Entity type:Individual
Prefix:
First Name:KATHY
Middle Name:L
Last Name:WIELICZKO
Suffix:
Gender:F
Credentials:MSN, CPNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6 GREENHILL CT
Mailing Address - Street 2:
Mailing Address - City:MARLTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08053-5379
Mailing Address - Country:US
Mailing Address - Phone:856-797-6591
Mailing Address - Fax:
Practice Address - Street 1:1ST FLOOR WOOD CENTER
Practice Address - Street 2:34TH & CIVIC CENTER BLVD
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19104
Practice Address - Country:US
Practice Address - Phone:215-590-3440
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-04
Last Update Date:2007-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP059690363LP0200X
NJ26NR09657400363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics