Healthcare Provider Details

I. General information

NPI: 1609104959
Provider Name (Legal Business Name): MICHELE A KRUCKMAN RN, CLC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/25/2009
Last Update Date: 12/12/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4410 REGENT ST
MADISON WI
53705-4901
US

IV. Provider business mailing address

N1639 FJORD CIR
PRAIRIE DU SAC WI
53578-9551
US

V. Phone/Fax

Practice location:
  • Phone: 608-233-9746
  • Fax: 608-233-9993
Mailing address:
  • Phone: 608-576-7894
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number168199-030
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code163WL0100X
TaxonomyLactation Consultant (Registered Nurse)
License Number207511
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: