Provider Demographics
NPI:1558952143
Name:LUCKETT, KIMBERLY
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:LUCKETT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:74 PAWTUXET TER
Mailing Address - Street 2:
Mailing Address - City:WEST WARWICK
Mailing Address - State:RI
Mailing Address - Zip Code:02893-5238
Mailing Address - Country:US
Mailing Address - Phone:401-626-1956
Mailing Address - Fax:
Practice Address - Street 1:795 MIDDLE ST
Practice Address - Street 2:
Practice Address - City:FALL RIVER
Practice Address - State:MA
Practice Address - Zip Code:02721-1733
Practice Address - Country:US
Practice Address - Phone:508-674-5600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-27
Last Update Date:2024-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIRN45277163W00000X
RI03955367500000X
MA2321346367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse