Provider Demographics
NPI:1477197812
Name:LUCKMAN, KIMBERLY G (NP)
Entity type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:G
Last Name:LUCKMAN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:505 JENKINS ST
Mailing Address - Street 2:
Mailing Address - City:LAGRANGE
Mailing Address - State:GA
Mailing Address - Zip Code:30240-4225
Mailing Address - Country:US
Mailing Address - Phone:706-407-0161
Mailing Address - Fax:706-756-1404
Practice Address - Street 1:505 JENKINS ST
Practice Address - Street 2:
Practice Address - City:LAGRANGE
Practice Address - State:GA
Practice Address - Zip Code:30240-4225
Practice Address - Country:US
Practice Address - Phone:706-407-0161
Practice Address - Fax:706-756-1404
Is Sole Proprietor?:No
Enumeration Date:2019-10-29
Last Update Date:2021-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN285427363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health