Provider Demographics
NPI:1508043670
Name:KUSICK, EILEEN JOYCE (RN)
Entity Type:Individual
Prefix:
First Name:EILEEN
Middle Name:JOYCE
Last Name:KUSICK
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:EILEEN
Other - Middle Name:JOYCE
Other - Last Name:DAHL / / / HEIDORN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPN / / / RN
Mailing Address - Street 1:25944 HILLCREST RD
Mailing Address - Street 2:
Mailing Address - City:DETROIT LAKES
Mailing Address - State:MN
Mailing Address - Zip Code:56501-7956
Mailing Address - Country:US
Mailing Address - Phone:218-234-9528
Mailing Address - Fax:
Practice Address - Street 1:106 N 4TH AVE
Practice Address - Street 2:
Practice Address - City:FERGUS FALLS
Practice Address - State:MN
Practice Address - Zip Code:56537-1034
Practice Address - Country:US
Practice Address - Phone:218-998-3778
Practice Address - Fax:218-998-3187
Is Sole Proprietor?:No
Enumeration Date:2008-01-30
Last Update Date:2008-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR123740-3163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse