Provider Demographics
NPI:1033312194
Name:DUCKWORTH, JOAN LYNN
Entity Type:Individual
Prefix:
First Name:JOAN
Middle Name:LYNN
Last Name:DUCKWORTH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5259 HICKORY HILL LN
Mailing Address - Street 2:
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49009-9557
Mailing Address - Country:US
Mailing Address - Phone:269-375-0605
Mailing Address - Fax:
Practice Address - Street 1:7000 PORTAGE ROAD
Practice Address - Street 2:
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49001
Practice Address - Country:US
Practice Address - Phone:269-833-9702
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704141638363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily