Provider Demographics
NPI:1457633497
Name:KACZMAREK, THERESA GLORIA (RN)
Entity Type:Individual
Prefix:MRS
First Name:THERESA
Middle Name:GLORIA
Last Name:KACZMAREK
Suffix:
Gender:F
Credentials:RN
Other - Prefix:MISS
Other - First Name:THERESA
Other - Middle Name:GLORIA
Other - Last Name:KRUEGER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:N15W30165 TIMBER BROOK RD
Mailing Address - Street 2:
Mailing Address - City:PEWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53072-6100
Mailing Address - Country:US
Mailing Address - Phone:262-844-0879
Mailing Address - Fax:
Practice Address - Street 1:N15W30165 TIMBER BROOK RD
Practice Address - Street 2:
Practice Address - City:PEWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53072-6100
Practice Address - Country:US
Practice Address - Phone:262-844-0879
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-15
Last Update Date:2011-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI117264-030163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse