Healthcare Provider Details

I. General information

NPI: 1073730065
Provider Name (Legal Business Name): STEPHANIE N LUECKEL M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/19/2007
Last Update Date: 11/19/2025
Certification Date: 11/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2 DUDLEY ST STE 470
PROVIDENCE RI
02905-3248
US

IV. Provider business mailing address

PO BOX 16149
RUMFORD RI
02916-0697
US

V. Phone/Fax

Practice location:
  • Phone: 401-228-0630
  • Fax: 401-868-2328
Mailing address:
  • Phone: 401-453-9625
  • Fax: 401-435-7069

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number225870
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code2086S0102X
TaxonomySurgical Critical Care Physician
License NumberMD14003
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: