Provider Demographics
NPI:1215694260
Name:LUCKIESH, ERIN NOELLE (NP)
Entity type:Individual
Prefix:
First Name:ERIN
Middle Name:NOELLE
Last Name:LUCKIESH
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3 SEMINOLE AVE
Mailing Address - Street 2:
Mailing Address - City:CORTE MADERA
Mailing Address - State:CA
Mailing Address - Zip Code:94925-1012
Mailing Address - Country:US
Mailing Address - Phone:415-747-1981
Mailing Address - Fax:
Practice Address - Street 1:3700 24TH ST
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94114-3904
Practice Address - Country:US
Practice Address - Phone:415-747-1981
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-24
Last Update Date:2021-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95009521363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics