Provider Demographics
NPI:1023157401
Name:WUJICK, FAWN E (MS)
Entity type:Individual
Prefix:
First Name:FAWN
Middle Name:E
Last Name:WUJICK
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2308 SYCAMORE AVE
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40206-2421
Mailing Address - Country:US
Mailing Address - Phone:502-693-1449
Mailing Address - Fax:188-851-1026
Practice Address - Street 1:2308 SYCAMORE AVE
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40206-2421
Practice Address - Country:US
Practice Address - Phone:502-693-1449
Practice Address - Fax:188-851-1026
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-05
Last Update Date:2024-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYKY-0170231H00000X
IN23002041A231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200209270Medicaid