Provider Demographics
NPI:1184086555
Name:LY-LUCAS, TRINH NIKKI
Entity type:Individual
Prefix:
First Name:TRINH NIKKI
Middle Name:
Last Name:LY-LUCAS
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 1:325 WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:EAST WALPOLE
Mailing Address - State:MA
Mailing Address - Zip Code:02032-1154
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:325 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:EAST WALPOLE
Practice Address - State:MA
Practice Address - Zip Code:02032-1154
Practice Address - Country:US
Practice Address - Phone:857-205-2976
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-24
Last Update Date:2016-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN2266772363L00000X, 363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care