Provider Demographics
NPI:1720333198
Name:LUCKY, LONUIS (CNA)
Entity Type:Individual
Prefix:
First Name:LONUIS
Middle Name:
Last Name:LUCKY
Suffix:
Gender:F
Credentials:CNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1625 CONLEY RD. 222
Mailing Address - Street 2:
Mailing Address - City:CONLEY
Mailing Address - State:GA
Mailing Address - Zip Code:30288
Mailing Address - Country:US
Mailing Address - Phone:770-318-1064
Mailing Address - Fax:
Practice Address - Street 1:1625 CONLEY RD. 222
Practice Address - Street 2:
Practice Address - City:CONLEY
Practice Address - State:GA
Practice Address - Zip Code:30288
Practice Address - Country:US
Practice Address - Phone:770-318-1064
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-20
Last Update Date:2012-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
372600000X, 374U00000X
GACN0030007375376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes372600000XNursing Service Related ProvidersAdult Companion
No374U00000XNursing Service Related ProvidersHome Health Aide
No376K00000XNursing Service Related ProvidersNurse's Aide