Provider Demographics
NPI:1457790362
Name:MELLENS, LUKE WALTER (RN)
Entity type:Individual
Prefix:
First Name:LUKE
Middle Name:WALTER
Last Name:MELLENS
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3318 N DAMEN AVE UNIT 3
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60618-6215
Mailing Address - Country:US
Mailing Address - Phone:312-320-6185
Mailing Address - Fax:
Practice Address - Street 1:3318 N DAMEN AVE UNIT 3
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60618-6215
Practice Address - Country:US
Practice Address - Phone:312-320-6185
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-06-24
Last Update Date:2013-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041.371240367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered