Healthcare Provider Details

I. General information

NPI: 1265491211
Provider Name (Legal Business Name): KAMIE JOY LUCAS ATC, LAT
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 03/20/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 E WASHINGTON BLVD INDIANA INSTITUTE OF TECHNOLOGY
FORT WAYNE IN
46803
US

IV. Provider business mailing address

1922 ARDMORE AVE APT. 54
FORT WAYNE IN
46802-4824
US

V. Phone/Fax

Practice location:
  • Phone: 260-422-5561
  • Fax:
Mailing address:
  • Phone: 260-557-5400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number36001232A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: