Provider Demographics
NPI:1003403957
Name:WANIEWSKI, TERESA MARIE
Entity Type:Individual
Prefix:
First Name:TERESA
Middle Name:MARIE
Last Name:WANIEWSKI
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 1:634 COELI DR
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43612-3309
Mailing Address - Country:US
Mailing Address - Phone:419-367-6597
Mailing Address - Fax:
Practice Address - Street 1:283 MONT ROYAL DR
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43608-1150
Practice Address - Country:US
Practice Address - Phone:419-356-3162
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-27
Last Update Date:2020-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376J00000XNursing Service Related ProvidersHomemaker
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH288-9405Medicaid