Basic Information
| Provider Information | |||||||||
| NPI: | 1205891371 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KUSIC | ||||||||
| FirstName: | MICHELLE | ||||||||
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| Credential: | CNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 525 E MARKET ST | ||||||||
| Address2: | ANNEX 3 | ||||||||
| City: | AKRON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 443041619 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3303757512 | ||||||||
| FaxNumber: | 3303753445 | ||||||||
| Practice Location | |||||||||
| Address1: | 75 ARCH ST | ||||||||
| Address2: | SUITE B1 | ||||||||
| City: | AKRON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 443041429 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3303754844 | ||||||||
| FaxNumber: | 3303754067 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/19/2006 | ||||||||
| LastUpdateDate: | 12/21/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | NP-01184 | OH | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 2030788 | 05 | OH | MEDICAID |