Provider Demographics
NPI:1639908601
Name:GILLIS, LUCINDA LOU KIL (NP)
Entity type:Individual
Prefix:MRS
First Name:LUCINDA
Middle Name:LOU KIL
Last Name:GILLIS
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:LUCINDA
Other - Middle Name:LOU
Other - Last Name:KIL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN, JD
Mailing Address - Street 1:3245 HEALTH DR STE 100
Mailing Address - Street 2:
Mailing Address - City:GRANGER
Mailing Address - State:IN
Mailing Address - Zip Code:46530-1380
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:707 N MICHIGAN ST STE 400
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46601-1071
Practice Address - Country:US
Practice Address - Phone:574-647-8470
Practice Address - Fax:574-647-8475
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-29
Last Update Date:2024-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71015554A363LP0808X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300098665Medicaid