Provider Demographics
NPI:1801415088
Name:LUCAS, KELLIE LYN (MD)
Entity Type:Individual
Prefix:
First Name:KELLIE
Middle Name:LYN
Last Name:LUCAS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:KELLIE
Other - Middle Name:LYN
Other - Last Name:MILAM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1978 INDUSTRIAL BLVD
Mailing Address - Street 2:
Mailing Address - City:HOUMA
Mailing Address - State:LA
Mailing Address - Zip Code:70363-7055
Mailing Address - Country:US
Mailing Address - Phone:985-873-2710
Mailing Address - Fax:
Practice Address - Street 1:1978 INDUSTRIAL BLVD
Practice Address - Street 2:
Practice Address - City:HOUMA
Practice Address - State:LA
Practice Address - Zip Code:70363-7055
Practice Address - Country:US
Practice Address - Phone:985-873-2710
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-08
Last Update Date:2023-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
GA95882207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program