Provider Demographics
NPI:1285101550
Name:KUKULSKI, LAURA E
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:E
Last Name:KUKULSKI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12811 S CEDAR LN
Mailing Address - Street 2:
Mailing Address - City:PALOS HEIGHTS
Mailing Address - State:IL
Mailing Address - Zip Code:60463-1916
Mailing Address - Country:US
Mailing Address - Phone:708-528-0988
Mailing Address - Fax:
Practice Address - Street 1:4101 1ST AVE
Practice Address - Street 2:
Practice Address - City:LYONS
Practice Address - State:IL
Practice Address - Zip Code:60534-1028
Practice Address - Country:US
Practice Address - Phone:708-447-6851
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-25
Last Update Date:2018-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209.018412363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner