Provider Demographics
NPI:1528174331
Name:LUCKY, DELORES A (C-FNP)
Entity type:Individual
Prefix:
First Name:DELORES
Middle Name:A
Last Name:LUCKY
Suffix:
Gender:F
Credentials:C-FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:818 ARBUCKLE ROAD
Mailing Address - Street 2:SUITE 102
Mailing Address - City:SUMMERSVILLE
Mailing Address - State:WV
Mailing Address - Zip Code:26651-1086
Mailing Address - Country:US
Mailing Address - Phone:304-883-2310
Mailing Address - Fax:304-883-2312
Practice Address - Street 1:818 ARBUCKLE ROAD
Practice Address - Street 2:SUITE 102
Practice Address - City:SUMMERSVILLE
Practice Address - State:WV
Practice Address - Zip Code:26651-1086
Practice Address - Country:US
Practice Address - Phone:304-883-2310
Practice Address - Fax:304-883-2312
Is Sole Proprietor?:No
Enumeration Date:2006-08-22
Last Update Date:2010-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV44396363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV7102018000Medicaid
WVLUNP6051Medicare ID - Type Unspecified
WV7102018000Medicaid