=====================================================
General NPI Number Information
=====================================================
NPI Number | 1013860055
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KRISTIE LUCKETT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/18/2026
-----------------------------------------------------
Last Update Date | 02/18/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5320 ENTERPRISE ST STE H
-----------------------------------------------------
City | SYKESVILLE
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21784-9354
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 410-756-0059
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2354 ERIN RD
-----------------------------------------------------
City | SYKESVILLE
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21784-6839
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2255A2300X
-----------------------------------------------------
Taxonomy Name | Athletic Trainer
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------