Provider Demographics
NPI:1659546919
Name:LUCIANO, KRISTY
Entity Type:Individual
Prefix:
First Name:KRISTY
Middle Name:
Last Name:LUCIANO
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 1:302 RANDALL ROAD
Mailing Address - Street 2:SUITE 106
Mailing Address - City:GENEVA
Mailing Address - State:IL
Mailing Address - Zip Code:60134
Mailing Address - Country:US
Mailing Address - Phone:630-232-7200
Mailing Address - Fax:630-232-2288
Practice Address - Street 1:302 RANDALL RD STE 106
Practice Address - Street 2:
Practice Address - City:GENEVA
Practice Address - State:IL
Practice Address - Zip Code:60134-4209
Practice Address - Country:US
Practice Address - Phone:630-232-7200
Practice Address - Fax:630-232-2288
Is Sole Proprietor?:No
Enumeration Date:2008-04-28
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085001279363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILML1710385OtherDEA REGISTRATION NUMBER