Healthcare Provider Details

I. General information

NPI: 1639117591
Provider Name (Legal Business Name): JAMES D LUCIUK CRNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/03/2006
Last Update Date: 06/28/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21 W 25TH ST
BALTIMORE MD
21218
US

IV. Provider business mailing address

201 N CHARLES ST STE 200
BALTIMORE MD
21201-4166
US

V. Phone/Fax

Practice location:
  • Phone: 410-366-1717
  • Fax: 410-889-4176
Mailing address:
  • Phone: 410-576-9191
  • Fax: 410-576-9257

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberR107868
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License NumberR107868
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: