Healthcare Provider Details

I. General information

NPI: 1598020158
Provider Name (Legal Business Name): KELLY ANN LUCIANO M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/10/2012
Last Update Date: 07/10/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

520 N 4TH ST
SPRINGFIELD IL
62702-5238
US

IV. Provider business mailing address

817 E COOK ST
SPRINGFIELD IL
62703-1625
US

V. Phone/Fax

Practice location:
  • Phone: 217-757-8100
  • Fax:
Mailing address:
  • Phone: 217-816-6854
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number125.061583
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: