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General NPI Number Information
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NPI Number | 1093156481
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Entity Type | Individual
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Provider Name | SHANNON LEE LUCZAK APN
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Gender | Female
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Dates
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Enumeration Date | 07/12/2013
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Last Update Date | 03/04/2019
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Provider Practice Location Address
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Address Line | 515 N LAFAYETTE BLVD
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City | SOUTH BEND
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State | IN
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Zip | 46601-1003
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Country | US
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Telephone | 574-232-2037
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Fax |
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Provider Business Mailing Address
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Address Line | 1531 S HALSTED ST UNIT 301
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City | CHICAGO
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State | IL
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Zip | 60607-5135
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Country | US
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Telephone | 989-482-7696
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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 | 367A00000X
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Taxonomy Name | Advanced Practice Midwife
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License Number |
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License Number State |
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