=====================================================
General NPI Number Information
=====================================================
NPI Number | 1629805130
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MATTHEW STEPHEN LUECKE FNP-BC
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/18/2024
-----------------------------------------------------
Last Update Date | 01/26/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1270 PALM COAST PKWY NW
-----------------------------------------------------
City | PALM COAST
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32137-4738
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 386-225-4631
-----------------------------------------------------
Fax | 386-597-2978
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1270 PALM COAST PKWY NW
-----------------------------------------------------
City | PALM COAST
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32137-4738
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 386-225-4631
-----------------------------------------------------
Fax | 386-597-2978
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | 71015791A
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 163W00000X
-----------------------------------------------------
Taxonomy Name | Registered Nurse
-----------------------------------------------------
License Number | 28248567A
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | 11038755
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------