Provider Demographics
NPI:1376018655
Name:LUCKEW, HALEY ALLISON
Entity Type:Individual
Prefix:
First Name:HALEY
Middle Name:ALLISON
Last Name:LUCKEW
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 1:1415 LILAC DR N STE 190
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55422-4544
Mailing Address - Country:US
Mailing Address - Phone:763-267-8701
Mailing Address - Fax:763-231-9602
Practice Address - Street 1:1415 LILAC DR N STE 190
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55422-4544
Practice Address - Country:US
Practice Address - Phone:763-267-8701
Practice Address - Fax:763-231-9602
Is Sole Proprietor?:No
Enumeration Date:2018-10-12
Last Update Date:2019-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN6126363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology