Provider Demographics
NPI:1821419821
Name:BACZKOWSKI, SHIRLEY MARIE (RN)
Entity Type:Individual
Prefix:
First Name:SHIRLEY
Middle Name:MARIE
Last Name:BACZKOWSKI
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8260 WICKER AVE.
Mailing Address - Street 2:LAKE CENTRAL SCHOOL CORPORATION
Mailing Address - City:SAINT JOHN
Mailing Address - State:IN
Mailing Address - Zip Code:46373
Mailing Address - Country:US
Mailing Address - Phone:219-365-8507
Mailing Address - Fax:219-865-4442
Practice Address - Street 1:210 E. JOLIET ST
Practice Address - Street 2:HOMAN ELEMENTARY
Practice Address - City:SCHERERVILLE
Practice Address - State:IN
Practice Address - Zip Code:46375
Practice Address - Country:US
Practice Address - Phone:219-322-4451
Practice Address - Fax:219-865-4442
Is Sole Proprietor?:No
Enumeration Date:2013-12-18
Last Update Date:2013-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28070896A163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse