Provider Demographics
NPI:1689187650
Name:LUCAS, TIA NICOLE
Entity Type:Individual
Prefix:MS
First Name:TIA
Middle Name:NICOLE
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 1:209 NE MAIN ST
Mailing Address - Street 2:
Mailing Address - City:ROCKY MOUNT
Mailing Address - State:NC
Mailing Address - Zip Code:27801-5301
Mailing Address - Country:US
Mailing Address - Phone:252-497-3661
Mailing Address - Fax:
Practice Address - Street 1:209 NE MAIN ST
Practice Address - Street 2:
Practice Address - City:ROCKY MOUNT
Practice Address - State:NC
Practice Address - Zip Code:27801-5301
Practice Address - Country:US
Practice Address - Phone:252-497-3661
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-13
Last Update Date:2017-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist