Provider Demographics
NPI:1871815712
Name:LUCAS, ELIZABETH ANNE (RN)
Entity Type:Individual
Prefix:MRS
First Name:ELIZABETH
Middle Name:ANNE
Last Name:LUCAS
Suffix:
Gender:F
Credentials:RN
Other - Prefix:MISS
Other - First Name:ELIZABETH
Other - Middle Name:ANNE
Other - Last Name:PEABODY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSN, RN, PMHNP-BC
Mailing Address - Street 1:17141 RYAN RD
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48212-1112
Mailing Address - Country:US
Mailing Address - Phone:313-369-1717
Mailing Address - Fax:
Practice Address - Street 1:17141 RYAN RD
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48212-1112
Practice Address - Country:US
Practice Address - Phone:313-369-1717
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-02-19
Last Update Date:2010-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704211535163WP0809X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163WP0809XNursing Service ProvidersRegistered NursePsychiatric/Mental Health, Adult