Healthcare Provider Details

I. General information

NPI: 1083552319
Provider Name (Legal Business Name): LUKA ANDERSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: ZOEY DECA ANDERSON

II. Dates (important events)

Enumeration Date: 03/25/2026
Last Update Date: 03/25/2026
Certification Date: 03/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1709 JUMER DR STE B
BLOOMINGTON IL
61704-0914
US

IV. Provider business mailing address

227 S ORR DR
NORMAL IL
61761-3223
US

V. Phone/Fax

Practice location:
  • Phone: 872-239-8292
  • Fax:
Mailing address:
  • Phone: 309-750-0312
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: