Provider Demographics
NPI:1477111789
Name:LUCKART, JULIE KATHLEEN
Entity Type:Individual
Prefix:
First Name:JULIE
Middle Name:KATHLEEN
Last Name:LUCKART
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 1:3119 NW IVY CIR
Mailing Address - Street 2:
Mailing Address - City:CAMAS
Mailing Address - State:WA
Mailing Address - Zip Code:98607-9357
Mailing Address - Country:US
Mailing Address - Phone:360-281-6642
Mailing Address - Fax:
Practice Address - Street 1:3119 NW IVY CIR
Practice Address - Street 2:
Practice Address - City:CAMAS
Practice Address - State:WA
Practice Address - Zip Code:98607-9357
Practice Address - Country:US
Practice Address - Phone:360-281-6642
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-01
Last Update Date:2019-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP60954345363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily