Healthcare Provider Details

I. General information

NPI: 1447370630
Provider Name (Legal Business Name): MARLIE E LUCAS FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/30/2007
Last Update Date: 02/07/2020
Certification Date: 02/07/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1810 MESQUITE AVE STE B
LAKE HAVASU CITY AZ
86403-5886
US

IV. Provider business mailing address

2002 N STOCKTON HILL RD STE 104
KINGMAN AZ
86401-4698
US

V. Phone/Fax

Practice location:
  • Phone: 804-554-9814
  • Fax: 480-776-0025
Mailing address:
  • Phone: 804-554-9814
  • Fax: 807-760-0254

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberAP3230
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberARNP1107982
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: