Healthcare Provider Details

I. General information

NPI: 1588183487
Provider Name (Legal Business Name): MEREDITH GRACE LUKENS PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MEREDITH WORRALL

II. Dates (important events)

Enumeration Date: 09/12/2017
Last Update Date: 12/12/2025
Certification Date: 12/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4241 STATE HIGHWAY 14
CHRISTOPHER IL
62822-1037
US

IV. Provider business mailing address

PO BOX 3988
CARBONDALE IL
62902-3988
US

V. Phone/Fax

Practice location:
  • Phone: 618-724-2401
  • Fax: 618-724-4628
Mailing address:
  • Phone: 618-457-5200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number085.006425
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: