Provider Demographics
NPI:1780308338
Name:LUCKNER, KATHLEEN MARY (ACCNS-AG)
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:MARY
Last Name:LUCKNER
Suffix:
Gender:F
Credentials:ACCNS-AG
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:719 JAMESTOWN WAY
Mailing Address - Street 2:
Mailing Address - City:WEST CHESTER
Mailing Address - State:PA
Mailing Address - Zip Code:19380-6486
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4755 OGLETOWN STANTON RD # 3E29
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:DE
Practice Address - Zip Code:19718-2200
Practice Address - Country:US
Practice Address - Phone:302-733-7453
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-28
Last Update Date:2022-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEL1-0048950163W00000X
DELV-0010137364SC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SC0200XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistCritical Care Medicine
No163W00000XNursing Service ProvidersRegistered Nurse