Provider Demographics
NPI:1487998464
Name:KUKLA, LISA (APN-BC)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:KUKLA
Suffix:
Gender:F
Credentials:APN-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4440 W. 95TH STREET
Mailing Address - Street 2:6TH FLOOR OPP, HEART & VASCULAR CENTER
Mailing Address - City:OAK LAWN
Mailing Address - State:IL
Mailing Address - Zip Code:60453
Mailing Address - Country:US
Mailing Address - Phone:708-684-7032
Mailing Address - Fax:708-520-1871
Practice Address - Street 1:4400 W 95TH ST
Practice Address - Street 2:POB 407
Practice Address - City:OAK LAWN
Practice Address - State:IL
Practice Address - Zip Code:60453-2654
Practice Address - Country:US
Practice Address - Phone:708-684-7026
Practice Address - Fax:708-684-7040
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-15
Last Update Date:2022-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209009621363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health