Provider Demographics
NPI:1871004838
Name:WIACEK, BRIDGET EILEEN (APN)
Entity Type:Individual
Prefix:MRS
First Name:BRIDGET
Middle Name:EILEEN
Last Name:WIACEK
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1800 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WHEATON
Mailing Address - State:IL
Mailing Address - Zip Code:60187-3112
Mailing Address - Country:US
Mailing Address - Phone:630-614-4960
Mailing Address - Fax:
Practice Address - Street 1:1800 N MAIN ST FL 2
Practice Address - Street 2:
Practice Address - City:WHEATON
Practice Address - State:IL
Practice Address - Zip Code:60187-3112
Practice Address - Country:US
Practice Address - Phone:630-315-6123
Practice Address - Fax:630-682-3727
Is Sole Proprietor?:No
Enumeration Date:2017-10-18
Last Update Date:2018-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209.015795363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health