Provider Demographics
NPI:1336623495
Name:LUECKEMAN, STACY
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:
Last Name:LUECKEMAN
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 1:6173 GREENVIEW CT
Mailing Address - Street 2:
Mailing Address - City:BURTON
Mailing Address - State:MI
Mailing Address - Zip Code:48509-2607
Mailing Address - Country:US
Mailing Address - Phone:810-347-7468
Mailing Address - Fax:
Practice Address - Street 1:6173 GREENVIEW CT
Practice Address - Street 2:
Practice Address - City:BURTON
Practice Address - State:MI
Practice Address - Zip Code:48509-2607
Practice Address - Country:US
Practice Address - Phone:810-347-7468
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-24
Last Update Date:2018-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601008834363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant