MEDICARE: NIKOLYA LUCKETT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251E00000X	Home Health Agency

General Provider Information

NPI Number	:	1053849554
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NIKOLYA LUCKETT

Provider Business Mailing Address
First Line	:	5625 JAGGER CT
Second Line	:
City	:	VIRGINIA BEACH
State	:	VA
Zip	:	23464-6723
Country	:	US
Telephone Number	:	757-303-4985
Fax Number	:

Provider Business Practice Location Address
First Line	:	5625 JAGGER CT
Second Line	:
City	:	VIRGINIA BEACH
State	:	VA
Zip	:	23464-6723
Country	:	US
Telephone Number	:	757-303-4985
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/27/2017
Last Update Date	:	07/21/2022

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Directions to “ NIKOLYA LUCKETT ” Practice Location

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