Provider Demographics
NPI:1134519507
Name:LUCK, AUDREY LUCY (LM)
Entity type:Individual
Prefix:MS
First Name:AUDREY
Middle Name:LUCY
Last Name:LUCK
Suffix:
Gender:F
Credentials:LM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16821 NE 6TH AVE
Mailing Address - Street 2:
Mailing Address - City:NORTH MIAMI BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33162-2405
Mailing Address - Country:US
Mailing Address - Phone:786-953-6534
Mailing Address - Fax:
Practice Address - Street 1:16821 NE 6TH AVE
Practice Address - Street 2:
Practice Address - City:NORTH MIAMI BEACH
Practice Address - State:FL
Practice Address - Zip Code:33162-2405
Practice Address - Country:US
Practice Address - Phone:786-953-6534
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-23
Last Update Date:2024-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMW286176B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes176B00000XOther Service ProvidersMidwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL13782579OtherCAQH NUMBER