Healthcare Provider Details

I. General information

NPI: 1346746799
Provider Name (Legal Business Name): MEGAN KUKIELSKI PA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/04/2018
Last Update Date: 04/04/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3801 WILLIAM D TATE AVE STE 800A
GRAPEVINE TX
76051-8755
US

IV. Provider business mailing address

4341 PALMDALE DR
PLANO TX
75024-7318
US

V. Phone/Fax

Practice location:
  • Phone: 817-612-4499
  • Fax: 855-295-2686
Mailing address:
  • Phone: 214-457-4288
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberPA11938
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: