Provider Demographics
NPI:1598197816
Name:ABBOTT, LUKE LEROY (RN)
Entity Type:Individual
Prefix:
First Name:LUKE
Middle Name:LEROY
Last Name:ABBOTT
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4328 PAGE AVE
Mailing Address - Street 2:
Mailing Address - City:MICHIGAN CENTER
Mailing Address - State:MI
Mailing Address - Zip Code:49254-1077
Mailing Address - Country:US
Mailing Address - Phone:517-764-3609
Mailing Address - Fax:
Practice Address - Street 1:4328 PAGE AVE
Practice Address - Street 2:
Practice Address - City:MICHIGAN CENTER
Practice Address - State:MI
Practice Address - Zip Code:49254-1077
Practice Address - Country:US
Practice Address - Phone:517-764-3609
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-08-09
Last Update Date:2013-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704196830163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse