Provider Demographics
NPI:1770504219
Name:LUCAS, CARRIE A (RN, FNP)
Entity Type:Individual
Prefix:
First Name:CARRIE
Middle Name:A
Last Name:LUCAS
Suffix:
Gender:F
Credentials:RN, FNP
Other - Prefix:
Other - First Name:CARRIE
Other - Middle Name:A
Other - Last Name:RIEDEL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 1027
Mailing Address - Street 2:
Mailing Address - City:JEFFERSON CITY
Mailing Address - State:MO
Mailing Address - Zip Code:65102-1027
Mailing Address - Country:US
Mailing Address - Phone:573-681-3767
Mailing Address - Fax:573-761-6947
Practice Address - Street 1:515 E PROMENADE ST
Practice Address - Street 2:
Practice Address - City:MEXICO
Practice Address - State:MO
Practice Address - Zip Code:65265-2966
Practice Address - Country:US
Practice Address - Phone:573-581-0157
Practice Address - Fax:573-581-4995
Is Sole Proprietor?:No
Enumeration Date:2006-07-21
Last Update Date:2024-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2002017293363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO421197005Medicaid
MO213660OtherBLUE SHIELD
MO758224OtherHEALTHLINK
MO758224OtherHEALTHLINK
MO213660OtherBLUE SHIELD
MO118080035Medicare PIN
MO831475236Medicare PIN