Provider Demographics
NPI:1003858150
Name:LUCKEY, CAROL R (NP)
Entity Type:Individual
Prefix:
First Name:CAROL
Middle Name:R
Last Name:LUCKEY
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O BOX 11567
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:TN
Mailing Address - Zip Code:38308
Mailing Address - Country:US
Mailing Address - Phone:731-661-0086
Mailing Address - Fax:731-660-9055
Practice Address - Street 1:120 E CHURCH ST
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:TN
Practice Address - Zip Code:38351
Practice Address - Country:US
Practice Address - Phone:731-968-0146
Practice Address - Fax:731-968-9398
Is Sole Proprietor?:No
Enumeration Date:2006-06-12
Last Update Date:2011-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNAPN0000005691363LP2300X
TNAPN5691363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN0000000031363OtherMEMPHIS MANAGED CARE (TLC
TN156102OtherUNISON
TN39006861Medicaid
4157526OtherBLUE CROSS BLUE SHIELD TN
TN3900686Medicaid
TN4083540OtherTN CARE SELECT
TN4083540OtherBLUE CROSS BLUE SHIELD TN
TN4083540OtherBLUE CROSS BLUE SHIELD TN
TN156102OtherUNISON
TN4083540OtherTN CARE SELECT