Provider Demographics
NPI:1669717468
Name:KACZMAREK, ELEONORA
Entity type:Individual
Prefix:
First Name:ELEONORA
Middle Name:
Last Name:KACZMAREK
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 1:2505 S 116TH AVE
Mailing Address - Street 2:
Mailing Address - City:AVONDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85323-7638
Mailing Address - Country:US
Mailing Address - Phone:623-444-9097
Mailing Address - Fax:
Practice Address - Street 1:2505 S 116TH AVE
Practice Address - Street 2:
Practice Address - City:AVONDALE
Practice Address - State:AZ
Practice Address - Zip Code:85323
Practice Address - Country:US
Practice Address - Phone:623-444-9097
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-12-05
Last Update Date:2012-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAL8568H372600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes372600000XNursing Service Related ProvidersAdult Companion