Healthcare Provider Details

I. General information

NPI: 1619995503
Provider Name (Legal Business Name): JUDITH ANN KASZYCA NURSE PRACTITONER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/18/2006
Last Update Date: 07/17/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3532 MAIN ST
DECKERVILLE MI
48427-9615
US

IV. Provider business mailing address

3532 MAIN ST
DECKERVILLE MI
48427-9615
US

V. Phone/Fax

Practice location:
  • Phone: 810-376-3100
  • Fax: 810-376-8311
Mailing address:
  • Phone: 810-376-3100
  • Fax: 810-376-8311

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number4704103116
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: