Provider Demographics
NPI:1033881412
Name:LUCKETT, CARMEN (LPN)
Entity Type:Individual
Prefix:
First Name:CARMEN
Middle Name:
Last Name:LUCKETT
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7458 W 64TH PL
Mailing Address - Street 2:
Mailing Address - City:SUMMIT
Mailing Address - State:IL
Mailing Address - Zip Code:60501-1922
Mailing Address - Country:US
Mailing Address - Phone:773-727-4855
Mailing Address - Fax:
Practice Address - Street 1:7458 W 64TH PL
Practice Address - Street 2:
Practice Address - City:SUMMIT
Practice Address - State:IL
Practice Address - Zip Code:60501-1922
Practice Address - Country:US
Practice Address - Phone:773-727-4855
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-04
Last Update Date:2021-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA043109504164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse