Provider Demographics
NPI:1558398834
Name:KRUTTLIN, KIANN (PAC)
Entity Type:Individual
Prefix:
First Name:KIANN
Middle Name:
Last Name:KRUTTLIN
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:205 N STATE ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:HARRISVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48740-9255
Mailing Address - Country:US
Mailing Address - Phone:989-724-5655
Mailing Address - Fax:989-358-3730
Practice Address - Street 1:205 N STATE ST
Practice Address - Street 2:SUITE A
Practice Address - City:HARRISVILLE
Practice Address - State:MI
Practice Address - Zip Code:48740-9255
Practice Address - Country:US
Practice Address - Phone:989-724-5655
Practice Address - Fax:989-358-3730
Is Sole Proprietor?:No
Enumeration Date:2006-06-26
Last Update Date:2021-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601001384363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
R697125Medicare UPIN