Healthcare Provider Details

I. General information

NPI: 1578815809
Provider Name (Legal Business Name): KELLY J LUECK FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/10/2012
Last Update Date: 07/03/2025
Certification Date: 07/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2946 E BANNER GATEWAY DR
GILBERT AZ
85234-2165
US

IV. Provider business mailing address

PO BOX 6095
BEND OR
97708-6095
US

V. Phone/Fax

Practice location:
  • Phone: 480-256-6444
  • Fax: 480-256-3682
Mailing address:
  • Phone: 541-706-5922
  • Fax: 541-706-6869

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number201610216NP-PP
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberTAP4690
License Number StateAZ
# 3
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number4042935
License Number StateKY
# 4
Primary TaxonomyN
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License NumberTAP4690
License Number StateAZ
# 5
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberTAP4690
License Number StateAZ
# 6
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number201610216NP-PP
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: