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General NPI Number Information
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NPI Number | 1063145712
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Entity Type | Individual
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Provider Name | MACKENZIE ANN LULLO AS, BAS, PTA
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Gender | Female
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Dates
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Enumeration Date | 07/08/2022
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Last Update Date | 07/08/2022
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Provider Practice Location Address
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Address Line | 23525 W MILTON RD
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City | WAUCONDA
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State | IL
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Zip | 60084-2619
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Country | US
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Telephone | 847-438-5400
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Fax |
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Provider Business Mailing Address
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Address Line | 1513 EVERGREEN ST
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City | HOLIDAY HILLS
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State | IL
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Zip | 60051-9128
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Country | US
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Telephone | 815-861-0856
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2081P0010X
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Taxonomy Name | Pediatric Rehabilitation Medicine Physician
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License Number | 160.009537
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License Number State | IL
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