Provider Demographics
NPI:1881160612
Name:LUECK, CARISSA SUSANNE (DNP)
Entity type:Individual
Prefix:DR
First Name:CARISSA
Middle Name:SUSANNE
Last Name:LUECK
Suffix:
Gender:F
Credentials:DNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18TH MEDICAL GROUP
Mailing Address - Street 2:UNIT 5142
Mailing Address - City:APO
Mailing Address - State:AP
Mailing Address - Zip Code:96368
Mailing Address - Country:US
Mailing Address - Phone:090-429-7369
Mailing Address - Fax:
Practice Address - Street 1:18TH MEDICAL GROUP
Practice Address - Street 2:UNIT 5142
Practice Address - City:APO
Practice Address - State:AP
Practice Address - Zip Code:96368
Practice Address - Country:US
Practice Address - Phone:315-630-4581
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-19
Last Update Date:2024-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE112513208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics