Provider Demographics
NPI:1760767040
Name:LUCKHARDT, DIANA LYNN (NP)
Entity Type:Individual
Prefix:
First Name:DIANA
Middle Name:LYNN
Last Name:LUCKHARDT
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1703 EAST MICHIGAN AVENUE
Mailing Address - Street 2:
Mailing Address - City:LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48912
Mailing Address - Country:US
Mailing Address - Phone:517-913-3860
Mailing Address - Fax:517-484-6864
Practice Address - Street 1:2622 HEARTLAND BLVD
Practice Address - Street 2:
Practice Address - City:IONIA
Practice Address - State:MI
Practice Address - Zip Code:48846-8757
Practice Address - Country:US
Practice Address - Phone:517-913-3860
Practice Address - Fax:517-484-6864
Is Sole Proprietor?:No
Enumeration Date:2011-10-18
Last Update Date:2011-10-24
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI4704130092363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health