Healthcare Provider Details

I. General information

NPI: 1609332840
Provider Name (Legal Business Name): DONNA LUCKETT FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/12/2019
Last Update Date: 08/12/2025
Certification Date: 08/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1175 VICKERY LN STE 101
CORDOVA TN
38016-0682
US

IV. Provider business mailing address

542 BUCK CREEK CV
HERNANDO MS
38632-8090
US

V. Phone/Fax

Practice location:
  • Phone: 662-408-6995
  • Fax: 901-425-9884
Mailing address:
  • Phone: 662-408-6995
  • Fax: 901-425-9884

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number25840
License Number StateTN

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: