Provider Demographics
NPI:1902250210
Name:LUCKE-WOLD, ANN (APRN)
Entity Type:Individual
Prefix:
First Name:ANN
Middle Name:
Last Name:LUCKE-WOLD
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:ANN
Other - Middle Name:NOELLE
Other - Last Name:MOUTRIE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:APRN
Mailing Address - Street 1:1 MEDICAL CENTER DRIVE
Mailing Address - Street 2:
Mailing Address - City:MORGANTOWN
Mailing Address - State:WV
Mailing Address - Zip Code:26506
Mailing Address - Country:US
Mailing Address - Phone:304-598-4800
Mailing Address - Fax:
Practice Address - Street 1:4645 NW 8TH AVE
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32605
Practice Address - Country:US
Practice Address - Phone:352-375-1212
Practice Address - Fax:352-416-0135
Is Sole Proprietor?:No
Enumeration Date:2016-04-22
Last Update Date:2018-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV87014363L00000X
FLARNP9484687363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner