Provider Demographics
NPI:1164705042
Name:LUCAITIS, KIMBERLY (FNP)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:LUCAITIS
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:
Other - Last Name:GOODRICH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:600 GRANT ST
Mailing Address - Street 2:
Mailing Address - City:GARY
Mailing Address - State:IN
Mailing Address - Zip Code:46402-6001
Mailing Address - Country:US
Mailing Address - Phone:219-886-4464
Mailing Address - Fax:
Practice Address - Street 1:600 GRANT ST
Practice Address - Street 2:
Practice Address - City:GARY
Practice Address - State:IN
Practice Address - Zip Code:46402-6001
Practice Address - Country:US
Practice Address - Phone:219-886-4464
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-27
Last Update Date:2016-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28141967A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily