Provider Demographics
NPI:1134600414
Name:LUCKIE, LISA MARIE (FNP-C)
Entity type:Individual
Prefix:MS
First Name:LISA
Middle Name:MARIE
Last Name:LUCKIE
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1349
Mailing Address - Street 2:
Mailing Address - City:FITZGERALD
Mailing Address - State:GA
Mailing Address - Zip Code:31750-1349
Mailing Address - Country:US
Mailing Address - Phone:229-423-8725
Mailing Address - Fax:
Practice Address - Street 1:182 PERRY HOUSE RD STE E
Practice Address - Street 2:
Practice Address - City:FITZGERALD
Practice Address - State:GA
Practice Address - Zip Code:31750-8714
Practice Address - Country:US
Practice Address - Phone:229-423-8725
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-24
Last Update Date:2018-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN170777363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily