Provider Demographics
NPI:1417642562
Name:FODCZUK, MICHELLE MARIE
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:MARIE
Last Name:FODCZUK
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 1:4926 N ISLAND DR E
Mailing Address - Street 2:
Mailing Address - City:BONNEY LAKE
Mailing Address - State:WA
Mailing Address - Zip Code:98391-8608
Mailing Address - Country:US
Mailing Address - Phone:425-365-6968
Mailing Address - Fax:425-365-5065
Practice Address - Street 1:4926 N ISLAND DR E
Practice Address - Street 2:
Practice Address - City:BONNEY LAKE
Practice Address - State:WA
Practice Address - Zip Code:98391-8608
Practice Address - Country:US
Practice Address - Phone:425-365-6968
Practice Address - Fax:425-386-5065
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-05
Last Update Date:2023-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WARN0119006163WC0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC0400XNursing Service ProvidersRegistered NurseCase Management