Mackenzie Ann Lullo, AS, BAS, PTA

Primary specialty

Pediatric Rehabilitation Medicine PhysicianTaxonomy code 2081P0010X

License

160.009537 Issued in IL

Practice address

23525 W Milton Rd
Wauconda, IL 60084-2619

Phone

(847) 438-5400

NPI assigned

Jul 8, 2022

Sex

Female

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Other identifiers 1

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Not enrolled

Credentials

Associate of Science

State licenses

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1657238400000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1657238400000",
    "number": "1063145712",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1513 EVERGREEN ST",
            "city": "HOLIDAY HILLS",
            "state": "IL",
            "postal_code": "600519128",
            "telephone_number": "815-861-0856"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "23525 W MILTON RD",
            "city": "WAUCONDA",
            "state": "IL",
            "postal_code": "600842619",
            "telephone_number": "847-438-5400"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "LULLO",
        "first_name": "MACKENZIE",
        "middle_name": "ANN",
        "credential": "AS, BAS, PTA",
        "sole_proprietor": "NO",
        "sex": "F",
        "enumeration_date": "2022-07-08",
        "last_updated": "2022-07-08",
        "certification_date": "2022-07-08",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "2081P0010X",
            "taxonomy_group": "",
            "desc": "Physical Medicine & Rehabilitation, Pediatric Rehabilitation Medicine",
            "state": "IL",
            "license": "160.009537",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "PEDIATRICS IN MOTION",
            "identifier": "1003094996",
            "state": "IL"
        }
    ],
    "endpoints": [],
    "other_names": []
}

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• Pediatric Rehabilitation Medicine Physician in Wauconda, IL
• Providers in Wauconda, IL by specialty
• Pediatric Rehabilitation Medicine Physician in Illinois

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 8, 2022; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.