Provider Demographics
NPI:1295923779
Name:LUSTENBERGER, KELLIE J (NP)
Entity type:Individual
Prefix:
First Name:KELLIE
Middle Name:J
Last Name:LUSTENBERGER
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:305 W JACKSON ST STE 100
Mailing Address - Street 2:
Mailing Address - City:CARBONDALE
Mailing Address - State:IL
Mailing Address - Zip Code:62901-1474
Mailing Address - Country:US
Mailing Address - Phone:618-457-0404
Mailing Address - Fax:618-457-0440
Practice Address - Street 1:305 W. JACKSON, SUITE 100
Practice Address - Street 2:NEW HORIZONS OBSTETRICS & GYNECOLOGY
Practice Address - City:CARBONDALE
Practice Address - State:IL
Practice Address - Zip Code:62901
Practice Address - Country:US
Practice Address - Phone:618-457-0404
Practice Address - Fax:618-457-0440
Is Sole Proprietor?:No
Enumeration Date:2007-10-09
Last Update Date:2008-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209006728363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILK50464Medicare PIN
IL709920Medicare PIN