Healthcare Provider Details

I. General information

NPI: 1851819114
Provider Name (Legal Business Name): MAUREEN KUDLICH LPN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/06/2017
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9040 JACKSON AVE ATTN:MCHJ-CLQ-C ATTN PATRICIA SHUSTER
TACOMA WA
98431-0001
US

IV. Provider business mailing address

3924 ROSSBERG ST SE
LACEY WA
98503-3592
US

V. Phone/Fax

Practice location:
  • Phone: 253-968-3869
  • Fax:
Mailing address:
  • Phone: 360-481-6461
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License NumberPN60603853
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: