Provider Demographics
NPI:1891727715
Name:KLUCZINSKE, MARLENE J (NP)
Entity type:Individual
Prefix:
First Name:MARLENE
Middle Name:J
Last Name:KLUCZINSKE
Suffix:
Gender:
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 735044
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60673-5044
Mailing Address - Country:US
Mailing Address - Phone:800-326-2250
Mailing Address - Fax:
Practice Address - Street 1:215 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:GRAFTON
Practice Address - State:WI
Practice Address - Zip Code:53024-1700
Practice Address - Country:US
Practice Address - Phone:262-268-6635
Practice Address - Fax:262-268-5118
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2025-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI53363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI43837700Medicaid
WIP00836845OtherRR MEDICARE
WI46236-0016Medicare PIN
WI43837700Medicaid
WIP00836845OtherRR MEDICARE