Provider Demographics
NPI:1093156481
Name:LUCZAK, SHANNON LEE (APN)
Entity Type:Individual
Prefix:MRS
First Name:SHANNON
Middle Name:LEE
Last Name:LUCZAK
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1531 S HALSTED ST UNIT 301
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60607-5135
Mailing Address - Country:US
Mailing Address - Phone:989-482-7696
Mailing Address - Fax:
Practice Address - Street 1:515 N LAFAYETTE BLVD
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46601-1003
Practice Address - Country:US
Practice Address - Phone:574-232-2037
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-07-12
Last Update Date:2019-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife