Healthcare Provider Details

I. General information

NPI: 1740284496
Provider Name (Legal Business Name): KIM LUCIANO APN, C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/10/2005
Last Update Date: 08/23/2022
Certification Date: 08/23/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

249 S MAIN ST STE 2
BARNEGAT NJ
08005-2369
US

IV. Provider business mailing address

401 ROUTE 73 N STE 320
MARLTON NJ
08053-3426
US

V. Phone/Fax

Practice location:
  • Phone: 609-607-1010
  • Fax:
Mailing address:
  • Phone: 609-607-1010
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2080P0214X
TaxonomyPediatric Pulmonology Physician
License Number26NN07311100
License Number StateNJ
# 2
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number26NN07311100
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: