Healthcare Provider Details

I. General information

NPI: 1558398834
Provider Name (Legal Business Name): KIANN KRUTTLIN P.A.C.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/26/2006
Last Update Date: 02/02/2021
Certification Date: 02/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

205 N STATE ST SUITE A
HARRISVILLE MI
48740-9255
US

IV. Provider business mailing address

205 N STATE ST SUITE A
HARRISVILLE MI
48740-9255
US

V. Phone/Fax

Practice location:
  • Phone: 989-724-5655
  • Fax: 989-358-3730
Mailing address:
  • Phone: 989-724-5655
  • Fax: 989-358-3730

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5601001384
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: