Provider Demographics
NPI:1780114157
Name:WISNIEWSKA, EDYTA KINGA (NP)
Entity type:Individual
Prefix:
First Name:EDYTA
Middle Name:KINGA
Last Name:WISNIEWSKA
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:32 SPRING ST APT 120
Mailing Address - Street 2:
Mailing Address - City:WALLINGTON
Mailing Address - State:NJ
Mailing Address - Zip Code:07057-2030
Mailing Address - Country:US
Mailing Address - Phone:551-795-3024
Mailing Address - Fax:
Practice Address - Street 1:173 FORT WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10032-3739
Practice Address - Country:US
Practice Address - Phone:212-305-2500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-18
Last Update Date:2019-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY715683-1163WC0200X, 363LA2100X
NJ26NR16881300163WC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No163WC0200XNursing Service ProvidersRegistered NurseCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJW46691947256904OtherDRIVER'S LICENSE