Provider Demographics
NPI:1093242851
Name:LUCKEY, SONIA GORDON (DNP, APRN)
Entity Type:Individual
Prefix:
First Name:SONIA
Middle Name:GORDON
Last Name:LUCKEY
Suffix:
Gender:F
Credentials:DNP, APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:503 VIA DESEO
Mailing Address - Street 2:
Mailing Address - City:SAN CLEMENTE
Mailing Address - State:CA
Mailing Address - Zip Code:92672-2462
Mailing Address - Country:US
Mailing Address - Phone:714-822-7195
Mailing Address - Fax:
Practice Address - Street 1:638 CAMINO DE LOS MARES
Practice Address - Street 2:
Practice Address - City:SAN CLEMENTE
Practice Address - State:CA
Practice Address - Zip Code:92673
Practice Address - Country:US
Practice Address - Phone:949-494-8426
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-11
Last Update Date:2021-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR202000873363LF0000X
WAAP60944156363LF0000X
CARN449787363LF0000X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily