Provider Demographics
NPI:1942928338
Name:WIKTORSKI, ANDREA CASAL CAETANO (LPN)
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:CASAL CAETANO
Last Name:WIKTORSKI
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:114 JACKSON ROAD EXT
Mailing Address - Street 2:
Mailing Address - City:PENFIELD
Mailing Address - State:NY
Mailing Address - Zip Code:14526-1239
Mailing Address - Country:US
Mailing Address - Phone:585-377-2568
Mailing Address - Fax:
Practice Address - Street 1:114 JACKSON ROAD EXT
Practice Address - Street 2:
Practice Address - City:PENFIELD
Practice Address - State:NY
Practice Address - Zip Code:14526-1239
Practice Address - Country:US
Practice Address - Phone:585-377-2568
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-22
Last Update Date:2022-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY307793-01164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse