Provider Demographics
NPI:1639853211
Name:SLUSARCZYK, KATHLEEN NICOLE
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:NICOLE
Last Name:SLUSARCZYK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1129 N JACKSON ST APT 406
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53202-3279
Mailing Address - Country:US
Mailing Address - Phone:847-323-5013
Mailing Address - Fax:
Practice Address - Street 1:1271 N 6TH ST
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53212-3360
Practice Address - Country:US
Practice Address - Phone:414-978-9100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-14
Last Update Date:2023-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI23654730363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily