Healthcare Provider Details

I. General information

NPI: 1730795295
Provider Name (Legal Business Name): DANA LYNN KUKOROLA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/21/2020
Last Update Date: 09/21/2020
Certification Date: 09/21/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

806 CASTLEGLEN DR APT 106
GARLAND TX
75043-5856
US

IV. Provider business mailing address

806 CASTLEGLEN DR APT 106
GARLAND TX
75043-5856
US

V. Phone/Fax

Practice location:
  • Phone: 214-642-2863
  • Fax:
Mailing address:
  • Phone: 214-642-2863
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164X00000X
TaxonomyLicensed Vocational Nurse
License Number343847
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: