Provider Demographics
NPI:1952823296
Name:LUCKIE, AMELIA M (RN)
Entity Type:Individual
Prefix:MS
First Name:AMELIA
Middle Name:M
Last Name:LUCKIE
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:430 E 162ND ST # 106
Mailing Address - Street 2:
Mailing Address - City:SOUTH HOLLAND
Mailing Address - State:IL
Mailing Address - Zip Code:60473-2258
Mailing Address - Country:US
Mailing Address - Phone:630-670-3336
Mailing Address - Fax:
Practice Address - Street 1:7405 CALIFORNIA AVE
Practice Address - Street 2:
Practice Address - City:HAMMOND
Practice Address - State:IN
Practice Address - Zip Code:46323
Practice Address - Country:US
Practice Address - Phone:630-670-3336
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-07
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL4203434171M00000X
IL041345850163WC0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC0400XNursing Service ProvidersRegistered NurseCase Management
No171M00000XOther Service ProvidersCase Manager/Care Coordinator