Provider Demographics
NPI:1043589237
Name:LUCK, CATHLEEN ANN (RN)
Entity Type:Individual
Prefix:MRS
First Name:CATHLEEN
Middle Name:ANN
Last Name:LUCK
Suffix:
Gender:F
Credentials:RN
Other - Prefix:MISS
Other - First Name:CATHLEEN
Other - Middle Name:ANN
Other - Last Name:SAND
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:677 EAST MAIN ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:CENTREVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:49032
Mailing Address - Country:US
Mailing Address - Phone:269-467-1000
Mailing Address - Fax:269-467-3075
Practice Address - Street 1:677 EAST MAIN ST
Practice Address - Street 2:SUITE A
Practice Address - City:CENTREVILLE
Practice Address - State:MI
Practice Address - Zip Code:49032
Practice Address - Country:US
Practice Address - Phone:269-467-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-12-19
Last Update Date:2011-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704287669163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1708146Medicaid