Provider Demographics
NPI:1316752496
Name:WIECZOREK, KAYLAN
Entity type:Individual
Prefix:
First Name:KAYLAN
Middle Name:
Last Name:WIECZOREK
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 1:1801 VIRGINIA DR
Mailing Address - Street 2:
Mailing Address - City:GRAND ISLAND
Mailing Address - State:NE
Mailing Address - Zip Code:68803-5030
Mailing Address - Country:US
Mailing Address - Phone:402-669-3905
Mailing Address - Fax:
Practice Address - Street 1:1801 VIRGINIA DRIVE
Practice Address - Street 2:
Practice Address - City:GRAND ISLAND
Practice Address - State:NE
Practice Address - Zip Code:68803-6880
Practice Address - Country:US
Practice Address - Phone:402-669-3905
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-02-07
Last Update Date:2025-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE139853376K00000X
372600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes372600000XNursing Service Related ProvidersAdult Companion
No376K00000XNursing Service Related ProvidersNurse's Aide