Provider Demographics
NPI:1891727715
Name:KLUCZINSKE, MARLENE J (NP)
Entity Type:Individual
Prefix:
First Name:MARLENE
Middle Name:J
Last Name:KLUCZINSKE
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 1:3003 W GOOD HOPE RD
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53209-2042
Mailing Address - Country:US
Mailing Address - Phone:414-352-3100
Mailing Address - Fax:
Practice Address - Street 1:1777 W GRAND AVE
Practice Address - Street 2:
Practice Address - City:PORT WASHINGTON
Practice Address - State:WI
Practice Address - Zip Code:53074-2077
Practice Address - Country:US
Practice Address - Phone:262-284-3456
Practice Address - Fax:262-284-4543
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2021-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI53363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIP00836845OtherRR MEDICARE
WI43837700Medicaid
WI46236-0016Medicare PIN
WI43837700Medicaid
WIP00836845OtherRR MEDICARE