Provider Demographics
NPI:1457129819
Name:LUKOSE, JAIMIE (NP)
Entity type:Individual
Prefix:MRS
First Name:JAIMIE
Middle Name:
Last Name:LUKOSE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:MS
Other - First Name:JAIMIE
Other - Middle Name:
Other - Last Name:VAYALIL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4222 N 12TH ST STE 200
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85014-6024
Mailing Address - Country:US
Mailing Address - Phone:027-959-2236
Mailing Address - Fax:602-795-9728
Practice Address - Street 1:4222 N 12TH ST STE 200
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85014-6024
Practice Address - Country:US
Practice Address - Phone:602-795-9223
Practice Address - Fax:602-795-9728
Is Sole Proprietor?:No
Enumeration Date:2023-12-15
Last Update Date:2024-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ237099363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily