Provider Demographics
NPI:1750650198
Name:LUCKENBILL, HEATHER L (CRNP)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:L
Last Name:LUCKENBILL
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1701 INNOVATION DR
Mailing Address - Street 2:
Mailing Address - City:YORK
Mailing Address - State:PA
Mailing Address - Zip Code:17408-8815
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1701 INNOVATION DR
Practice Address - Street 2:
Practice Address - City:YORK
Practice Address - State:PA
Practice Address - Zip Code:17408-8815
Practice Address - Country:US
Practice Address - Phone:717-850-4040
Practice Address - Fax:717-850-4144
Is Sole Proprietor?:No
Enumeration Date:2011-12-14
Last Update Date:2021-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP012880363L00000X, 363LP0200X
PA018033363L00000X
NJNJ00356100363LP0200X
PARN556384163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJNJ00356100OtherMEDICAL LICENSE