Provider Demographics
NPI:1922315993
Name:WACK, KATHLEEN S
Entity Type:Individual
Prefix:MS
First Name:KATHLEEN
Middle Name:S
Last Name:WACK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1365 N JOHNSON AVE
Mailing Address - Street 2:SUITE 111
Mailing Address - City:EL CAJON
Mailing Address - State:CA
Mailing Address - Zip Code:92020-1676
Mailing Address - Country:US
Mailing Address - Phone:619-440-4801
Mailing Address - Fax:
Practice Address - Street 1:1365 N JOHNSON AVE
Practice Address - Street 2:SUITE 111
Practice Address - City:EL CAJON
Practice Address - State:CA
Practice Address - Zip Code:92020-1676
Practice Address - Country:US
Practice Address - Phone:619-440-4801
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-10
Last Update Date:2010-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174H00000XOther Service ProvidersHealth Educator