Provider Demographics
NPI:1871091876
Name:GOLUCKE, ANNETTE MICHELLE (CPNP-PC)
Entity type:Individual
Prefix:
First Name:ANNETTE
Middle Name:MICHELLE
Last Name:GOLUCKE
Suffix:
Gender:F
Credentials:CPNP-PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:122 W JOHN CARPENTER FWY STE 420
Mailing Address - Street 2:
Mailing Address - City:IRVING
Mailing Address - State:TX
Mailing Address - Zip Code:75039-2014
Mailing Address - Country:US
Mailing Address - Phone:972-957-3000
Mailing Address - Fax:
Practice Address - Street 1:1512 N ZARAGOZA RD STE A1
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79936-8903
Practice Address - Country:US
Practice Address - Phone:915-855-7700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-25
Last Update Date:2021-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP135944363LP0200X
NMCNP-03554363LP0200X
NMCNP03554363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM659321YRNDOtherMEDICARE
NM49451821Medicaid