Basic Information
| Provider Information | |||||||||
| NPI: | 1457435224 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LUCKS | ||||||||
| FirstName: | DIANE | ||||||||
| MiddleName: | B. | ||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | MIDWIFE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 200 GARDEN CITY PLAZA | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | GARDEN CITY | ||||||||
| State: | NY | ||||||||
| PostalCode: | 11530 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5166636400 | ||||||||
| FaxNumber: | 5166636404 | ||||||||
| Practice Location | |||||||||
| Address1: | 79 GRAND AVE | ||||||||
| Address2: | |||||||||
| City: | MASSAPEQUA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117584905 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5167983376 | ||||||||
| FaxNumber: | 5167985882 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/25/2006 | ||||||||
| LastUpdateDate: | 05/04/2009 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367A00000X | F000126 | NY | N | Physician Assistants & Advanced Practice Nursing Providers | Advanced Practice Midwife | 367A00000X | F000126-1 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Advanced Practice Midwife | 363L00000X | 376143-1 | NY | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | F00126 | 01 | NY | MIDWIFE LICENSE | OTHER | ML000128 | 01 | DEA NUMBER | OTHER |