=====================================================
General NPI Number Information
=====================================================
NPI Number | 1205418753
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MONIQUE C. LUCKETT-CUMMINGS FNP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/24/2021
-----------------------------------------------------
Last Update Date | 12/12/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10 WOODS RD
-----------------------------------------------------
City | VALHALLA
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10595-1529
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 917-371-8441
-----------------------------------------------------
Fax | 914-231-1203
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3650 VARIAN AVE
-----------------------------------------------------
City | BRONX
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10466-5935
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 917-371-8441
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363L00000X
-----------------------------------------------------
Taxonomy Name | Nurse Practitioner
-----------------------------------------------------
License Number | 348196
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | 658951
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 163WC1600X
-----------------------------------------------------
Taxonomy Name | Continuing Education/Staff Development Registered Nurse
-----------------------------------------------------
License Number | 658951
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------