Healthcare Provider Details

I. General information

NPI: 1174508840
Provider Name (Legal Business Name): JEFFREY PAUL WIENCEK FNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/14/2005
Last Update Date: 09/28/2023
Certification Date: 09/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3723 FRANKLIN ST
MICHIGAN CITY IN
46360-7310
US

IV. Provider business mailing address

PO BOX 781076
DETROIT MI
48278-1076
US

V. Phone/Fax

Practice location:
  • Phone: 219-874-3313
  • Fax: 219-878-2330
Mailing address:
  • Phone: 317-528-4800
  • Fax: 317-865-1479

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number71000502A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: