Provider Demographics
NPI:1457827628
Name:KANUCKEL, DOUGLAS L
Entity Type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:L
Last Name:KANUCKEL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:213 E CHESTNUT ST
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:OH
Mailing Address - Zip Code:43050-3404
Mailing Address - Country:US
Mailing Address - Phone:740-326-9255
Mailing Address - Fax:
Practice Address - Street 1:213 E CHESTNUT ST
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:OH
Practice Address - Zip Code:43050-3404
Practice Address - Country:US
Practice Address - Phone:740-326-9255
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-16
Last Update Date:2018-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator