Healthcare Provider Details

I. General information

NPI: 1487998464
Provider Name (Legal Business Name): LISA KUKLA APN-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/15/2012
Last Update Date: 04/25/2022
Certification Date: 04/25/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4400 W 95TH ST POB 407
OAK LAWN IL
60453-2654
US

IV. Provider business mailing address

4440 W. 95TH STREET 6TH FLOOR OPP, HEART & VASCULAR CENTER
OAK LAWN IL
60453
US

V. Phone/Fax

Practice location:
  • Phone: 708-684-7026
  • Fax: 708-684-7040
Mailing address:
  • Phone: 708-684-7032
  • Fax: 708-520-1871

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number209009621
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: