Provider Demographics
NPI:1295506798
Name:LUCAS, KELLY JO
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:JO
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 1:670 W ACADEMY ST
Mailing Address - Street 2:
Mailing Address - City:RANDLEMAN
Mailing Address - State:NC
Mailing Address - Zip Code:27317-9748
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:670 W ACADEMY ST
Practice Address - Street 2:
Practice Address - City:RANDLEMAN
Practice Address - State:NC
Practice Address - Zip Code:27317-9748
Practice Address - Country:US
Practice Address - Phone:336-498-8500
Practice Address - Fax:336-498-8522
Is Sole Proprietor?:No
Enumeration Date:2024-01-12
Last Update Date:2024-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC292083363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5019530OtherNP
NC292083OtherRN