Healthcare Provider Details

I. General information

NPI: 1003083684
Provider Name (Legal Business Name): MRS. AMANDA REBECCA LUCKE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/13/2008
Last Update Date: 10/30/2023
Certification Date: 10/30/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11501 CUMBERLAND RD STE 500
FISHERS IN
46037-7010
US

IV. Provider business mailing address

PO BOX 603725
CHARLOTTE NC
28260-3725
US

V. Phone/Fax

Practice location:
  • Phone: 317-863-9300
  • Fax: 317-863-9333
Mailing address:
  • Phone: 828-575-2625
  • Fax: 828-350-2174

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number71002639A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: