Provider Demographics
NPI:1609015510
Name:LUCKOSE, ANNE B (APN, NP-C)
Entity Type:Individual
Prefix:MRS
First Name:ANNE
Middle Name:B
Last Name:LUCKOSE
Suffix:
Gender:F
Credentials:APN, NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1052 W LOYOLA AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60626-5206
Mailing Address - Country:US
Mailing Address - Phone:773-508-2540
Mailing Address - Fax:773-508-2242
Practice Address - Street 1:1052 W. LOYOLA AVENUE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60626
Practice Address - Country:US
Practice Address - Phone:773-508-2540
Practice Address - Fax:773-508-2242
Is Sole Proprietor?:No
Enumeration Date:2009-02-17
Last Update Date:2013-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041340115363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL041340115OtherIL STATE LICENSE