Provider Demographics
NPI:1215117072
Name:KACZYNSKI, WENDY RENE'
Entity type:Individual
Prefix:MRS
First Name:WENDY
Middle Name:RENE'
Last Name:KACZYNSKI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5616 MAXWELL PL
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28409-2966
Mailing Address - Country:US
Mailing Address - Phone:910-793-9996
Mailing Address - Fax:
Practice Address - Street 1:4620 CEDAR AVE
Practice Address - Street 2:SUITE 118
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28403-4424
Practice Address - Country:US
Practice Address - Phone:910-790-5150
Practice Address - Fax:910-790-9011
Is Sole Proprietor?:No
Enumeration Date:2007-11-09
Last Update Date:2007-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8301324BMedicaid