Provider Demographics
NPI:1629170949
Name:KRUGER, MARCELLA N (NP)
Entity Type:Individual
Prefix:MRS
First Name:MARCELLA
Middle Name:N
Last Name:KRUGER
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:206 N. PEARL
Mailing Address - Street 2:
Mailing Address - City:TEUTOPOLIS
Mailing Address - State:IL
Mailing Address - Zip Code:62467
Mailing Address - Country:US
Mailing Address - Phone:217-857-6481
Mailing Address - Fax:217-857-6094
Practice Address - Street 1:206 N. PEARL ST.
Practice Address - Street 2:
Practice Address - City:TEUTOPOLIS
Practice Address - State:IL
Practice Address - Zip Code:62467
Practice Address - Country:US
Practice Address - Phone:217-857-6481
Practice Address - Fax:217-857-6094
Is Sole Proprietor?:No
Enumeration Date:2006-09-05
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
P64730Medicare UPIN
202425Medicare ID - Type UnspecifiedMEDICARE DIRECT BILL #