Provider Demographics
NPI:1356990915
Name:KUKULKA, MICHAEL LAMAR
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:LAMAR
Last Name:KUKULKA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2602 GLACIER ST
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99508-3772
Mailing Address - Country:US
Mailing Address - Phone:907-843-1664
Mailing Address - Fax:
Practice Address - Street 1:1355 W BLOOMFIELD RD STE 3
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47403-2051
Practice Address - Country:US
Practice Address - Phone:812-200-2789
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-06
Last Update Date:2023-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK195749363LF0000X
IN71009326A363LP0808X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health