Provider Demographics
NPI:1740600063
Name:STUKENBORG, KAY
Entity Type:Individual
Prefix:
First Name:KAY
Middle Name:
Last Name:STUKENBORG
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 1:5030 POLEN DR
Mailing Address - Street 2:
Mailing Address - City:KETTERING
Mailing Address - State:OH
Mailing Address - Zip Code:45440-2442
Mailing Address - Country:US
Mailing Address - Phone:937-499-1830
Mailing Address - Fax:937-499-1839
Practice Address - Street 1:5030 POLEN DR
Practice Address - Street 2:
Practice Address - City:KETTERING
Practice Address - State:OH
Practice Address - Zip Code:45440-2442
Practice Address - Country:US
Practice Address - Phone:937-499-1830
Practice Address - Fax:937-499-1839
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-25
Last Update Date:2014-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH132519163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse