Healthcare Provider Details

I. General information

NPI: 1356990915
Provider Name (Legal Business Name): MICHAEL LAMAR KUKULKA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/06/2019
Last Update Date: 08/02/2023
Certification Date: 08/02/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1355 W BLOOMFIELD RD STE 3
BLOOMINGTON IN
47403-2051
US

IV. Provider business mailing address

2602 GLACIER ST
ANCHORAGE AK
99508-3772
US

V. Phone/Fax

Practice location:
  • Phone: 812-200-2789
  • Fax:
Mailing address:
  • Phone: 907-843-1664
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number195749
License Number StateAK
# 2
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number71009326A
License Number StateIN
# 3
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number71009326A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: