Provider Demographics
NPI:1245455468
Name:WYKOWSKA, JOLANTA AGNIESZKA (OPTICIAN)
Entity type:Individual
Prefix:
First Name:JOLANTA
Middle Name:AGNIESZKA
Last Name:WYKOWSKA
Suffix:
Gender:F
Credentials:OPTICIAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6543 MYRTLE AVE
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:NY
Mailing Address - Zip Code:11385-7028
Mailing Address - Country:US
Mailing Address - Phone:718-366-7850
Mailing Address - Fax:718-366-7851
Practice Address - Street 1:6543 MYRTLE AVE
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:NY
Practice Address - Zip Code:11385-7028
Practice Address - Country:US
Practice Address - Phone:718-366-7850
Practice Address - Fax:718-366-7851
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYC008153-1156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician