Provider Demographics
NPI:1447370630
Name:LUCAS, MARLIE E (FNP-BC)
Entity type:Individual
Prefix:
First Name:MARLIE
Middle Name:E
Last Name:LUCAS
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2002 N STOCKTON HILL RD
Mailing Address - Street 2:STE 104
Mailing Address - City:KINGMAN
Mailing Address - State:AZ
Mailing Address - Zip Code:86401-4698
Mailing Address - Country:US
Mailing Address - Phone:804-554-9814
Mailing Address - Fax:807-760-0254
Practice Address - Street 1:1810 MESQUITE AVE STE B
Practice Address - Street 2:
Practice Address - City:LAKE HAVASU CITY
Practice Address - State:AZ
Practice Address - Zip Code:86403-5886
Practice Address - Country:US
Practice Address - Phone:804-554-9814
Practice Address - Fax:480-776-0025
Is Sole Proprietor?:No
Enumeration Date:2007-03-30
Last Update Date:2020-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP1107982363LF0000X
AZAP3230363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLE6192YMedicare PIN
FLP40058Medicare UPIN
FL0471260003Medicare NSC