Healthcare Provider Details

I. General information

NPI: 1588175392
Provider Name (Legal Business Name): AMY M KUKUCKA NURSE PRACTITIONER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/19/2017
Last Update Date: 08/28/2025
Certification Date: 08/28/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1543 COUNTRY CLUB RD # A
FAIRMONT WV
26554-1306
US

IV. Provider business mailing address

1543 COUNTRY CLUB RD # A
FAIRMONT WV
26554-1306
US

V. Phone/Fax

Practice location:
  • Phone: 304-363-2273
  • Fax:
Mailing address:
  • Phone: 304-363-2273
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberAPRN.CNP.021822
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number123735
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: