Provider Demographics
NPI:1194152231
Name:LUKING, CARISSA RENAE (FNP-C)
Entity type:Individual
Prefix:
First Name:CARISSA
Middle Name:RENAE
Last Name:LUKING
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:429 PERRY ST
Mailing Address - Street 2:
Mailing Address - City:VINCENNES
Mailing Address - State:IN
Mailing Address - Zip Code:47591-2127
Mailing Address - Country:US
Mailing Address - Phone:812-494-2920
Mailing Address - Fax:812-494-2924
Practice Address - Street 1:903 N 7TH ST
Practice Address - Street 2:
Practice Address - City:VINCENNES
Practice Address - State:IN
Practice Address - Zip Code:47591-3107
Practice Address - Country:US
Practice Address - Phone:812-316-0707
Practice Address - Fax:812-316-0702
Is Sole Proprietor?:No
Enumeration Date:2013-10-03
Last Update Date:2018-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71004665A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN71004665AOtherLICENSE
IN201193500Medicaid
IN71004665AOtherLICENSE