Healthcare Provider Details

I. General information

NPI: 1750169439
Provider Name (Legal Business Name): MRS. MARY M LUCIANI
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/15/2023
Last Update Date: 09/15/2023
Certification Date: 11/14/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 JEFFERSON AVE SE
GRAND RAPIDS MI
49503-4502
US

IV. Provider business mailing address

9053 HEARTHSTONE DR
ZIONSVILLE IN
46077-5514
US

V. Phone/Fax

Practice location:
  • Phone: 317-828-3956
  • Fax:
Mailing address:
  • Phone: 317-828-3956
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code364SA2200X
TaxonomyAdult Health Clinical Nurse Specialist
License Number4704394196
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: