Provider Demographics
NPI:1144820515
Name:KURTYAK, MICHELLE
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:KURTYAK
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 1:103 DODE DR
Mailing Address - Street 2:
Mailing Address - City:DOWNS
Mailing Address - State:IL
Mailing Address - Zip Code:61736-2002
Mailing Address - Country:US
Mailing Address - Phone:309-824-1648
Mailing Address - Fax:
Practice Address - Street 1:300 GREENBRIAR DR # 1125
Practice Address - Street 2:
Practice Address - City:NORMAL
Practice Address - State:IL
Practice Address - Zip Code:61761-2278
Practice Address - Country:US
Practice Address - Phone:309-451-1200
Practice Address - Fax:309-451-1203
Is Sole Proprietor?:No
Enumeration Date:2020-10-27
Last Update Date:2020-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051289596183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist