Provider Demographics
NPI:1437723277
Name:WIECZOREK, MAGDALENA (PMNP-BC)
Entity Type:Individual
Prefix:
First Name:MAGDALENA
Middle Name:
Last Name:WIECZOREK
Suffix:
Gender:F
Credentials:PMNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14 RYANS WAY
Mailing Address - Street 2:
Mailing Address - City:BURLINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06013-1822
Mailing Address - Country:US
Mailing Address - Phone:860-539-7538
Mailing Address - Fax:
Practice Address - Street 1:187 S CANAAN RD
Practice Address - Street 2:
Practice Address - City:CANAAN
Practice Address - State:CT
Practice Address - Zip Code:06018-2544
Practice Address - Country:US
Practice Address - Phone:860-824-1397
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-17
Last Update Date:2021-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT96722084A0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084A0401XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyAddiction Medicine