Provider Demographics
NPI:1003034646
Name:KUKUSELIS, PATRICIA (LMT)
Entity Type:Individual
Prefix:MS
First Name:PATRICIA
Middle Name:
Last Name:KUKUSELIS
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1506 IDLEWOOD DR
Mailing Address - Street 2:
Mailing Address - City:CLARKSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47129-1332
Mailing Address - Country:US
Mailing Address - Phone:812-945-2369
Mailing Address - Fax:
Practice Address - Street 1:1506 IDLEWOOD DR
Practice Address - Street 2:
Practice Address - City:CLARKSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47129-1332
Practice Address - Country:US
Practice Address - Phone:812-945-2369
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYKY-0140174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist