Provider Demographics
NPI:1851843999
Name:CAPULONG, WAYNE THOMAS
Entity Type:Individual
Prefix:MR
First Name:WAYNE
Middle Name:THOMAS
Last Name:CAPULONG
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16767 JULIANA AVE
Mailing Address - Street 2:
Mailing Address - City:EASTPOINTE
Mailing Address - State:MI
Mailing Address - Zip Code:48021-3009
Mailing Address - Country:US
Mailing Address - Phone:313-618-9492
Mailing Address - Fax:
Practice Address - Street 1:16767 JULIANA AVE
Practice Address - Street 2:
Practice Address - City:EASTPOINTE
Practice Address - State:MI
Practice Address - Zip Code:48021-3009
Practice Address - Country:US
Practice Address - Phone:313-618-9492
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-24
Last Update Date:2016-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704319378163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse