Provider Demographics
NPI:1821349390
Name:WIENCZAK, LAUREN (ANP-BC)
Entity Type:Individual
Prefix:MRS
First Name:LAUREN
Middle Name:
Last Name:WIENCZAK
Suffix:
Gender:F
Credentials:ANP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5701 BOW POINTE DR
Mailing Address - Street 2:STE 300
Mailing Address - City:CLARKSTON
Mailing Address - State:MI
Mailing Address - Zip Code:48346-5402
Mailing Address - Country:US
Mailing Address - Phone:248-346-5008
Mailing Address - Fax:
Practice Address - Street 1:2812 STEEPLECHASE
Practice Address - Street 2:
Practice Address - City:HIGHLAND
Practice Address - State:MI
Practice Address - Zip Code:48357-4251
Practice Address - Country:US
Practice Address - Phone:248-346-5008
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-09-25
Last Update Date:2019-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704268596363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health