Healthcare Provider Details

I. General information

NPI: 1003858150
Provider Name (Legal Business Name): CAROL R LUCKEY NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/12/2006
Last Update Date: 10/12/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 E CHURCH ST
LEXINGTON TN
38351
US

IV. Provider business mailing address

P.O BOX 11567
JACKSON TN
38308
US

V. Phone/Fax

Practice location:
  • Phone: 731-968-0146
  • Fax: 731-968-9398
Mailing address:
  • Phone: 731-661-0086
  • Fax: 731-660-9055

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberAPN5691
License Number StateTN
# 2
Primary TaxonomyY
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License NumberAPN0000005691
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: