Provider Demographics
NPI:1881767762
Name:LUCKEY, JOAN MARIE (APRN,BC)
Entity type:Individual
Prefix:
First Name:JOAN
Middle Name:MARIE
Last Name:LUCKEY
Suffix:
Gender:F
Credentials:APRN,BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:109 E ELM ST
Mailing Address - Street 2:
Mailing Address - City:STREATOR
Mailing Address - State:IL
Mailing Address - Zip Code:61364-2223
Mailing Address - Country:US
Mailing Address - Phone:815-672-4587
Mailing Address - Fax:815-673-3582
Practice Address - Street 1:109 E ELM ST
Practice Address - Street 2:
Practice Address - City:STREATOR
Practice Address - State:IL
Practice Address - Zip Code:61364-2223
Practice Address - Country:US
Practice Address - Phone:815-672-4587
Practice Address - Fax:815-673-3582
Is Sole Proprietor?:No
Enumeration Date:2006-11-16
Last Update Date:2011-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209-001759363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL209-001759OtherSTATE LICENSE NUMBER
P43761Medicare UPIN