MEDICARE: MICHELLE MARIE FODCZUK

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
1	163WC0400X	Case Management Registered Nurse	RN0119006	WA

General Provider Information

NPI Number	:	1417642562
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MICHELLE MARIE FODCZUK

Provider Business Mailing Address
First Line	:	4926 N ISLAND DR E
Second Line	:
City	:	BONNEY LAKE
State	:	WA
Zip	:	98391-8608
Country	:	US
Telephone Number	:	425-365-6968
Fax Number	:	425-365-5065

Provider Business Practice Location Address
First Line	:	4926 N ISLAND DR E
Second Line	:
City	:	BONNEY LAKE
State	:	WA
Zip	:	98391-8608
Country	:	US
Telephone Number	:	425-365-6968
Fax Number	:	425-386-5065

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/05/2023
Last Update Date	:	04/05/2023

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