Provider Demographics
NPI:1114560182
Name:KLUCZINSKE, MICHELLE (RN)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:KLUCZINSKE
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:39180 LIBERTY ST STE 205
Mailing Address - Street 2:
Mailing Address - City:FREMONT
Mailing Address - State:CA
Mailing Address - Zip Code:94538-2586
Mailing Address - Country:US
Mailing Address - Phone:510-617-5699
Mailing Address - Fax:
Practice Address - Street 1:39180 LIBERTY ST STE 205
Practice Address - Street 2:
Practice Address - City:FREMONT
Practice Address - State:CA
Practice Address - Zip Code:94538-2586
Practice Address - Country:US
Practice Address - Phone:510-617-5699
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-23
Last Update Date:2023-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY712240163W00000X
NY404183363LP0808X
CA95021862363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse