Healthcare Provider Details

I. General information

NPI: 1457435224
Provider Name (Legal Business Name): DIANE B. LUCKS MIDWIFE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/25/2006
Last Update Date: 03/07/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

79 GRAND AVE
MASSAPEQUA NY
11758-4905
US

IV. Provider business mailing address

200 GARDEN CITY PLAZA SUITE 100
GARDEN CITY NY
11530
US

V. Phone/Fax

Practice location:
  • Phone: 516-798-3376
  • Fax: 516-798-5882
Mailing address:
  • Phone: 516-663-6400
  • Fax: 516-663-6404

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number376143-1
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code367A00000X
TaxonomyAdvanced Practice Midwife
License NumberF000126
License Number StateNY
# 3
Primary TaxonomyY
Taxonomy Code367A00000X
TaxonomyAdvanced Practice Midwife
License NumberF000126-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: