1003083684 NPI number — MRS. AMANDA REBECCA LUCKE

Table of content: MRS. AMANDA REBECCA LUCKE (NPI 1003083684)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1003083684 NPI number — MRS. AMANDA REBECCA LUCKE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LUCKE
Provider First Name:
AMANDA
Provider Middle Name:
REBECCA
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1003083684
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/30/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 603725
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHARLOTTE
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28260-3725
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
828-575-2625
Provider Business Mailing Address Fax Number:
828-350-2174

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
11501 CUMBERLAND RD STE 500
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FISHERS
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46037-7010
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
317-863-9300
Provider Business Practice Location Address Fax Number:
317-863-9333
Provider Enumeration Date:
05/13/2008

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363L00000X , with the licence number:  71002639A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: IN1125030 . This is a "MEDICARE PTAN" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: IN1126018 . This is a "MEDICARE PTAN" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 200921940 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".