Provider Demographics
NPI:1609104959
Name:KRUCKMAN, MICHELE A (RN, CLC)
Entity Type:Individual
Prefix:
First Name:MICHELE
Middle Name:A
Last Name:KRUCKMAN
Suffix:
Gender:F
Credentials:RN, CLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:N1639 FJORD CIR
Mailing Address - Street 2:
Mailing Address - City:PRAIRIE DU SAC
Mailing Address - State:WI
Mailing Address - Zip Code:53578-9551
Mailing Address - Country:US
Mailing Address - Phone:608-576-7894
Mailing Address - Fax:
Practice Address - Street 1:4410 REGENT ST
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53705-4901
Practice Address - Country:US
Practice Address - Phone:608-233-9746
Practice Address - Fax:608-233-9993
Is Sole Proprietor?:No
Enumeration Date:2009-11-25
Last Update Date:2014-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI168199-030163W00000X
WI207511163WL0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WL0100XNursing Service ProvidersRegistered NurseLactation Consultant
No163W00000XNursing Service ProvidersRegistered Nurse