Healthcare Provider Details

I. General information

NPI: 1578941571
Provider Name (Legal Business Name): ANGELA KUKLEWSKI NURSE PRACTITIONER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/11/2015
Last Update Date: 03/19/2024
Certification Date: 03/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 MONROE AVENUE NW STE 104
GRAND RAPIDS MI
49503-1470
US

IV. Provider business mailing address

8348 LITTLE ROAD STE 149
NEW PORT RICHEY FL
34654-4919
US

V. Phone/Fax

Practice location:
  • Phone: 616-366-4234
  • Fax: 855-548-4481
Mailing address:
  • Phone: 616-366-4234
  • Fax: 855-548-4481

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number4704229854
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: