Healthcare Provider Details

I. General information

NPI: 1548626575
Provider Name (Legal Business Name): KEISHA PRUITT LUCKEY RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/06/2016
Last Update Date: 01/06/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2500 N STATE ST 2500 NORTH STATE STREET
JACKSON MS
39216-4500
US

IV. Provider business mailing address

2254 WOODLAND PL
FLORENCE MS
39073-9771
US

V. Phone/Fax

Practice location:
  • Phone: 601-984-5682
  • Fax: 601-815-3672
Mailing address:
  • Phone: 601-421-9291
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WD0400X
TaxonomyDiabetes Educator Registered Nurse
License NumberR863378
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: