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NPI Code Detail

MEDICARE: MRS. CAROLE ANNE DERUCKI FNP-BC

MEDICARE: MRS. CAROLE ANNE DERUCKI FNP-BC
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1174400000XSpecialist71002723AIN
2363L00000XNurse Practitioner4704166108MI
3363L00000XNurse Practitioner71002723AIN
4363LF0000XFamily Nurse Practitioner4704166108MI

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3000000723347OTHERINBCBS
4MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
54704166108OTHERMIMICHIGAN

General Provider Information

NPI Number : 1205809225
Entity Type Code : Individual
Provider Name (Legal Business Name) : MRS. CAROLE ANNE DERUCKI FNP-BC
Provider Business Mailing Address
First Line : 23448 SHURTE ST
Second Line :
City : CASSOPOLIS
State : MI
Zip : 49031-9738
Country : US
Telephone Number : 574-993-1158
Fax Number : 269-408-4346
Provider Business Practice Location Address
First Line : 2900 LAKEVIEW AVE
Second Line :
City : SAINT JOSEPH
State : MI
Zip : 49085-2379
Country : US
Telephone Number : 269-932-7859
Fax Number : 269-932-7859
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 02/09/2006
Last Update Date : 02/29/2024

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Directions to “ MRS. CAROLE ANNE DERUCKI FNP-BC” Practice Location

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