Basic Information
| Provider Information | |||||||||
| NPI: | 1487998464 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KUKLA | ||||||||
| FirstName: | LISA | ||||||||
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| Credential: | APN-BC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4440 W. 95TH STREET | ||||||||
| Address2: | 6TH FLOOR OPP, HEART & VASCULAR CENTER | ||||||||
| City: | OAK LAWN | ||||||||
| State: | IL | ||||||||
| PostalCode: | 60453 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7086847032 | ||||||||
| FaxNumber: | 7085201871 | ||||||||
| Practice Location | |||||||||
| Address1: | 4400 W 95TH ST | ||||||||
| Address2: | POB 407 | ||||||||
| City: | OAK LAWN | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604532654 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7086847026 | ||||||||
| FaxNumber: | 7086847040 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/15/2012 | ||||||||
| LastUpdateDate: | 04/25/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 04/25/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2200X | 209009621 | IL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health |
No ID Information.