Provider Demographics
NPI:1396392890
Name:LUCAS, CAROL A
Entity Type:Individual
Prefix:
First Name:CAROL
Middle Name:A
Last Name:LUCAS
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 1:805 POWELL AVE
Mailing Address - Street 2:
Mailing Address - City:COLLINSVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62234-3134
Mailing Address - Country:US
Mailing Address - Phone:618-407-2298
Mailing Address - Fax:
Practice Address - Street 1:805 POWELL AVE
Practice Address - Street 2:
Practice Address - City:COLLINSVILLE
Practice Address - State:IL
Practice Address - Zip Code:62234-3134
Practice Address - Country:US
Practice Address - Phone:618-407-2298
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-20
Last Update Date:2019-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider