Healthcare Provider Details

I. General information

NPI: 1285101550
Provider Name (Legal Business Name): LAURA E KUKULSKI
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/25/2018
Last Update Date: 10/25/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4101 1ST AVE
LYONS IL
60534-1028
US

IV. Provider business mailing address

12811 S CEDAR LN
PALOS HEIGHTS IL
60463-1916
US

V. Phone/Fax

Practice location:
  • Phone: 708-447-6851
  • Fax:
Mailing address:
  • Phone: 708-528-0988
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number209.018412
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: