Provider Demographics
NPI:1821081332
Name:KUKULICH, PAULA MARIA (CFNP)
Entity Type:Individual
Prefix:
First Name:PAULA
Middle Name:MARIA
Last Name:KUKULICH
Suffix:
Gender:F
Credentials:CFNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 17334
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21297-1334
Mailing Address - Country:US
Mailing Address - Phone:703-443-6717
Mailing Address - Fax:703-443-8643
Practice Address - Street 1:44055 RIVERSIDE PKWY
Practice Address - Street 2:SUITE 110
Practice Address - City:LEESBURG
Practice Address - State:VA
Practice Address - Zip Code:20176-5179
Practice Address - Country:US
Practice Address - Phone:703-724-7530
Practice Address - Fax:703-858-2870
Is Sole Proprietor?:No
Enumeration Date:2005-08-30
Last Update Date:2011-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024118994363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA7788045Medicaid
VAC06319Medicare PIN
S69894Medicare UPIN
VA7788045Medicaid