Basic Information
Provider Information | |||||||||
NPI: | 1639471311 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | LUCKANISH | ||||||||
FirstName: | AMANDA | ||||||||
MiddleName: | FLORENCE | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | NP-C | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | JOYCE | ||||||||
OtherFirstName: | AMANDA | ||||||||
OtherMiddleName: | FLORENCE | ||||||||
OtherNamePrefix: | MS. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | NP-C | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 2 PENNS WAY | ||||||||
Address2: | SUITE 412 | ||||||||
City: | NEW CASTLE | ||||||||
State: | DE | ||||||||
PostalCode: | 19720 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3026522455 | ||||||||
FaxNumber: | 3023226251 | ||||||||
Practice Location | |||||||||
Address1: | 1802 W 4TH ST | ||||||||
Address2: |   | ||||||||
City: | WILMINGTON | ||||||||
State: | DE | ||||||||
PostalCode: | 19805 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3026522455 | ||||||||
FaxNumber: | 3023226251 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/01/2010 | ||||||||
LastUpdateDate: | 04/05/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | LG-0000520 | DE | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.