Healthcare Provider Details

I. General information

NPI: 1013352558
Provider Name (Legal Business Name): LUCKNIE OVINCY PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/09/2013
Last Update Date: 05/09/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

50 NEWARK AVE
BELLEVILLE NJ
07109-1185
US

IV. Provider business mailing address

245 S BURNETT ST
EAST ORANGE NJ
07018-2502
US

V. Phone/Fax

Practice location:
  • Phone: 973-751-2060
  • Fax:
Mailing address:
  • Phone: 862-452-7882
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number25MP00297800
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: