Provider Demographics
NPI:1336814599
Name:PRUCKNIC, ALICIA ANNE (RN, BSN, CCM)
Entity Type:Individual
Prefix:MRS
First Name:ALICIA
Middle Name:ANNE
Last Name:PRUCKNIC
Suffix:
Gender:F
Credentials:RN, BSN, CCM
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Other - First Name:
Other - Middle Name:
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Mailing Address - Street 1:23772 WEST RD # 262
Mailing Address - Street 2:
Mailing Address - City:BROWNSTOWN TWP
Mailing Address - State:MI
Mailing Address - Zip Code:48183-3050
Mailing Address - Country:US
Mailing Address - Phone:734-788-9111
Mailing Address - Fax:734-941-3264
Practice Address - Street 1:23772 WEST RD # 262
Practice Address - Street 2:
Practice Address - City:BROWNSTOWN TWP
Practice Address - State:MI
Practice Address - Zip Code:48183-3050
Practice Address - Country:US
Practice Address - Phone:734-788-9111
Practice Address - Fax:734-941-3264
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-10
Last Update Date:2024-04-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI4704244622163WC0400X, 364SP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SP0808XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health
No163WC0400XNursing Service ProvidersRegistered NurseCase Management