Healthcare Provider Details

I. General information

NPI: 1336701556
Provider Name (Legal Business Name): JUELA KUCI PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/08/2019
Last Update Date: 07/08/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

259 MACK AVE
DETROIT MI
48201-2427
US

IV. Provider business mailing address

259 MACK AVE
DETROIT MI
48201-2427
US

V. Phone/Fax

Practice location:
  • Phone: 313-577-1716
  • Fax:
Mailing address:
  • Phone: 248-635-6522
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5601009195
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: