Healthcare Provider Details

I. General information

NPI: 1386241867
Provider Name (Legal Business Name): ANDREW KOCIUBUK APNP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/07/2020
Last Update Date: 10/01/2025
Certification Date: 10/01/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 HIGH SERVICE AVE
NORTH PROVIDENCE RI
02904-5113
US

IV. Provider business mailing address

200 HIGH SERVICE AVE
NORTH PROVIDENCE RI
02904-5113
US

V. Phone/Fax

Practice location:
  • Phone: 401-456-2000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number11039-33
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License NumberRN.466178
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: