Healthcare Provider Details

I. General information

NPI: 1215694260
Provider Name (Legal Business Name): ERIN NOELLE LUCKIESH NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/24/2021
Last Update Date: 11/24/2021
Certification Date: 11/24/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3700 24TH ST
SAN FRANCISCO CA
94114-3904
US

IV. Provider business mailing address

3 SEMINOLE AVE
CORTE MADERA CA
94925-1012
US

V. Phone/Fax

Practice location:
  • Phone: 415-747-1981
  • Fax:
Mailing address:
  • Phone: 415-747-1981
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number95009521
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: