Healthcare Provider Details

I. General information

NPI: 1770504219
Provider Name (Legal Business Name): CARRIE A LUCAS RN, FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: CARRIE A RIEDEL

II. Dates (important events)

Enumeration Date: 07/21/2006
Last Update Date: 03/05/2024
Certification Date: 03/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

515 E PROMENADE ST
MEXICO MO
65265-2966
US

IV. Provider business mailing address

PO BOX 1027
JEFFERSON CITY MO
65102-1027
US

V. Phone/Fax

Practice location:
  • Phone: 573-581-0157
  • Fax: 573-581-4995
Mailing address:
  • Phone: 573-681-3767
  • Fax: 573-761-6947

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number2002017293
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: