Provider Demographics
NPI:1780126474
Name:WIECZOREK, JODI ANN (AGCNS-BC, APRN)
Entity type:Individual
Prefix:
First Name:JODI
Middle Name:ANN
Last Name:WIECZOREK
Suffix:
Gender:F
Credentials:AGCNS-BC, APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:552 RED OAK CT
Mailing Address - Street 2:
Mailing Address - City:EAGAN
Mailing Address - State:MN
Mailing Address - Zip Code:55121-2335
Mailing Address - Country:US
Mailing Address - Phone:651-402-8993
Mailing Address - Fax:
Practice Address - Street 1:201 E NICOLLET BLVD
Practice Address - Street 2:
Practice Address - City:BURNSVILLE
Practice Address - State:MN
Practice Address - Zip Code:55337-5714
Practice Address - Country:US
Practice Address - Phone:952-892-2000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-11
Last Update Date:2016-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR 118342-1 CNS 0516364S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364S00000XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse Specialist