Provider Demographics
NPI:1619243938
Name:LUCAS, LINDA DIANNE (REGISTERED NURSE)
Entity Type:Individual
Prefix:MRS
First Name:LINDA
Middle Name:DIANNE
Last Name:LUCAS
Suffix:
Gender:F
Credentials:REGISTERED NURSE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4905 FORSYTH RD
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31210-4401
Mailing Address - Country:US
Mailing Address - Phone:478-471-1700
Mailing Address - Fax:478-471-1222
Practice Address - Street 1:4905 FORSYTH RD
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31210-4401
Practice Address - Country:US
Practice Address - Phone:478-471-1700
Practice Address - Fax:478-471-1222
Is Sole Proprietor?:No
Enumeration Date:2012-03-30
Last Update Date:2012-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN058252163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA182875008AMedicaid
GA00370609BMedicaid