Provider Demographics
NPI:1154503167
Name:KUCKUCK, STEPHANIE MARGARET (RN)
Entity Type:Individual
Prefix:MRS
First Name:STEPHANIE
Middle Name:MARGARET
Last Name:KUCKUCK
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 1:2414 S STATE ROAD 5
Mailing Address - Street 2:
Mailing Address - City:LARWILL
Mailing Address - State:IN
Mailing Address - Zip Code:46764-9766
Mailing Address - Country:US
Mailing Address - Phone:260-723-4179
Mailing Address - Fax:260-723-4101
Practice Address - Street 1:2414 S STATE ROAD 5
Practice Address - Street 2:
Practice Address - City:LARWILL
Practice Address - State:IN
Practice Address - Zip Code:46764-9766
Practice Address - Country:US
Practice Address - Phone:260-723-4179
Practice Address - Fax:260-723-4101
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-30
Last Update Date:2007-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY553962-1163WH0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WH0200XNursing Service ProvidersRegistered NurseHome Health