=====================================================
General NPI Number Information
=====================================================
NPI Number | 1669129722
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | EBONY LUCAS
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/08/2022
-----------------------------------------------------
Last Update Date | 03/08/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3007 BERNICE RD
-----------------------------------------------------
City | LANSING
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60438-1243
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 312-826-6277
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3007 BERNICE RD
-----------------------------------------------------
City | LANSING
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60438-1243
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 312-826-6277
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 374U00000X
-----------------------------------------------------
Taxonomy Name | Home Health Aide
-----------------------------------------------------
License Number | 22020493626L
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------