Healthcare Provider Details

I. General information

NPI: 1134112485
Provider Name (Legal Business Name): MARCIA ANN KLUCK CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/23/2005
Last Update Date: 09/08/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2650 RIVERSIDE LN NE
ROCHESTER MN
55906
US

IV. Provider business mailing address

2650 RIVERSIDE LN NE
ROCHESTER MN
55906-3455
US

V. Phone/Fax

Practice location:
  • Phone: 507-421-7293
  • Fax:
Mailing address:
  • Phone: 507-421-7293
  • Fax: 507-289-0384

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WG0000X
TaxonomyGeneral Practice Registered Nurse
License NumberR 093453-2
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number046716
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: