Provider Demographics
NPI:1003083684
Name:LUCKE, AMANDA REBECCA
Entity Type:Individual
Prefix:MRS
First Name:AMANDA
Middle Name:REBECCA
Last Name:LUCKE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 603725
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-3725
Mailing Address - Country:US
Mailing Address - Phone:828-575-2625
Mailing Address - Fax:828-350-2174
Practice Address - Street 1:11501 CUMBERLAND RD STE 500
Practice Address - Street 2:
Practice Address - City:FISHERS
Practice Address - State:IN
Practice Address - Zip Code:46037-7010
Practice Address - Country:US
Practice Address - Phone:317-863-9300
Practice Address - Fax:317-863-9333
Is Sole Proprietor?:No
Enumeration Date:2008-05-13
Last Update Date:2023-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71002639A363L00000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
ININ1125030OtherMEDICARE PTAN
ININ1126018OtherMEDICARE PTAN
IN200921940Medicaid