Healthcare Provider Details

I. General information

NPI: 1255966008
Provider Name (Legal Business Name): ANNA KUDICK LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/11/2020
Last Update Date: 03/11/2020
Certification Date: 03/11/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1005 EASTERN AVE
PLYMOUTH WI
53073-1920
US

IV. Provider business mailing address

2202 DIVISION ST
MANITOWOC WI
54220-6028
US

V. Phone/Fax

Practice location:
  • Phone: 920-419-4727
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number10617-146
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: