Basic Information
| Provider Information | |||||||||
| NPI: | 1619995503 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KASZYCA | ||||||||
| FirstName: | JUDITH | ||||||||
| MiddleName: | ANN | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | NURSE PRACTITONER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3532 MAIN ST | ||||||||
| Address2: | |||||||||
| City: | DECKERVILLE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 484279615 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8103763100 | ||||||||
| FaxNumber: | 8103768311 | ||||||||
| Practice Location | |||||||||
| Address1: | 3532 MAIN ST | ||||||||
| Address2: | |||||||||
| City: | DECKERVILLE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 484279615 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8103763100 | ||||||||
| FaxNumber: | 8103768311 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/18/2006 | ||||||||
| LastUpdateDate: | 07/17/2007 | ||||||||
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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 | 363LA2200X | 4704103116 | MI | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health |
ID Information
| ID | Type | State | Issuer | Description | 18073 | 05 | MI | MEDICAID |