Provider Demographics
NPI:1487033643
Name:KUCZYNSKI, ELLEN (CTRS)
Entity Type:Individual
Prefix:
First Name:ELLEN
Middle Name:
Last Name:KUCZYNSKI
Suffix:
Gender:F
Credentials:CTRS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6644 CHECKERBERRY LN NE
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:MI
Mailing Address - Zip Code:49341-8918
Mailing Address - Country:US
Mailing Address - Phone:616-450-2643
Mailing Address - Fax:
Practice Address - Street 1:6644 CHECKERBERRY LN NE
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:MI
Practice Address - Zip Code:49341-8918
Practice Address - Country:US
Practice Address - Phone:616-450-2643
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-05-21
Last Update Date:2015-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI63331164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse