Healthcare Provider Details

I. General information

NPI: 1770932170
Provider Name (Legal Business Name): MALLORY NOELLE LUCKEY M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/07/2016
Last Update Date: 04/04/2024
Certification Date: 04/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

640 PUDDINGSTONE PKWY
BANNER ELK NC
28604-7418
US

IV. Provider business mailing address

640 PUDDINGSTONE PKWY
BANNER ELK NC
28604-7418
US

V. Phone/Fax

Practice location:
  • Phone: 864-237-4021
  • Fax: 864-778-8417
Mailing address:
  • Phone: 864-237-4021
  • Fax: 864-778-8417

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberLL39661
License Number StateSC
# 2
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number2022-01271
License Number StateNC
# 3
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License NumberME159060
License Number StateFL
# 4
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number2023006973
License Number StateMO
# 5
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License NumberMD214178
License Number StateOR
# 6
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number302609
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: