Healthcare Provider Details

I. General information

NPI: 1750890919
Provider Name (Legal Business Name): LUCAS JOHN SPEAK ARNP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/20/2017
Last Update Date: 07/21/2022
Certification Date: 02/11/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5882 KILKENNY MNR
CLARENCE CENTER NY
14032
US

IV. Provider business mailing address

5882 KILKENNY MNR
CLARENCE CENTER NY
14032-9430
US

V. Phone/Fax

Practice location:
  • Phone: 954-812-1265
  • Fax:
Mailing address:
  • Phone: 954-812-1265
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number342293
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number3432293
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: