Provider Demographics
NPI:1124393053
Name:CARLUCCI, MELISSA (APN)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:CARLUCCI
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 1:845 S DAMEN AVE
Mailing Address - Street 2:M/C 802
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60612-3727
Mailing Address - Country:US
Mailing Address - Phone:312-413-0054
Mailing Address - Fax:312-996-4979
Practice Address - Street 1:2242 W HARRISON ST
Practice Address - Street 2:STE 204
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-3719
Practice Address - Country:US
Practice Address - Phone:312-996-7708
Practice Address - Fax:312-413-0503
Is Sole Proprietor?:No
Enumeration Date:2012-03-09
Last Update Date:2012-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209008630363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care