Healthcare Provider Details

I. General information

NPI: 1063036747
Provider Name (Legal Business Name): CHRISTINE KUCYK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/29/2020
Last Update Date: 10/17/2023
Certification Date: 10/17/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15717 15 MILE RD
CLINTON TOWNSHIP MI
48035-2101
US

IV. Provider business mailing address

15855 19 MILE RD
CLINTON TOWNSHIP MI
48038-3504
US

V. Phone/Fax

Practice location:
  • Phone: 586-263-2980
  • Fax: 586-263-2825
Mailing address:
  • Phone: 586-263-2980
  • Fax: 586-263-2825

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5601010040
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: