Healthcare Provider Details

I. General information

NPI: 1366641391
Provider Name (Legal Business Name): ALYSSA CORYNE DZIONDZIAK RN, CWON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/11/2007
Last Update Date: 09/08/2022
Certification Date: 09/08/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

W243N2331 SADDLE BROOK DR APT 2
PEWAUKEE WI
53072-6420
US

IV. Provider business mailing address

W243N2331 SADDLE BROOK DR APT 2
PEWAUKEE WI
53072-6420
US

V. Phone/Fax

Practice location:
  • Phone: 414-530-8760
  • Fax:
Mailing address:
  • Phone: 414-530-8760
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WW0000X
TaxonomyWound Care Registered Nurse
License Number186756
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: