Healthcare Provider Details

I. General information

NPI: 1003279837
Provider Name (Legal Business Name): ANGELA NGUYEN KIENUTSKE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/30/2016
Last Update Date: 08/25/2026
Certification Date: 08/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

71 124TH AVE
SHELBYVILLE MI
49344-9772
US

IV. Provider business mailing address

71 124TH AVE
SHELBYVILLE MI
49344-9772
US

V. Phone/Fax

Practice location:
  • Phone: 269-672-7774
  • Fax:
Mailing address:
  • Phone: 269-672-7774
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number5302041200
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: