Healthcare Provider Details

I. General information

NPI: 1164047510
Provider Name (Legal Business Name): AUTUMN FAWN STEWART LUCKEY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/11/2020
Last Update Date: 05/08/2025
Certification Date: 05/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11303 W WASHINGTON BLVD STE 200
LOS ANGELES CA
90066-6003
US

IV. Provider business mailing address

11303 W WASHINGTON BLVD STE 200
LOS ANGELES CA
90066-6003
US

V. Phone/Fax

Practice location:
  • Phone: 310-482-6600
  • Fax: 310-313-0973
Mailing address:
  • Phone: 310-482-6600
  • Fax: 310-313-0973

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: