Healthcare Provider Details

I. General information

NPI: 1205418753
Provider Name (Legal Business Name): MONIQUE C. LUCKETT-CUMMINGS FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/24/2021
Last Update Date: 12/12/2021
Certification Date: 12/12/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10 WOODS RD
VALHALLA NY
10595-1529
US

IV. Provider business mailing address

3650 VARIAN AVE
BRONX NY
10466-5935
US

V. Phone/Fax

Practice location:
  • Phone: 917-371-8441
  • Fax: 914-231-1203
Mailing address:
  • Phone: 917-371-8441
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number348196
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number658951
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code163WC1600X
TaxonomyContinuing Education/Staff Development Registered Nurse
License Number658951
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: