Provider Demographics
NPI:1629266028
Name:LUCKETT, TIMOTHY PRYOR (REGISTERED NURSE)
Entity Type:Individual
Prefix:MR
First Name:TIMOTHY
Middle Name:PRYOR
Last Name:LUCKETT
Suffix:
Gender:M
Credentials:REGISTERED NURSE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14171 SHEPHERD DR
Mailing Address - Street 2:
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91739-2215
Mailing Address - Country:US
Mailing Address - Phone:909-268-2126
Mailing Address - Fax:909-899-8850
Practice Address - Street 1:14171 SHEPHERD DR
Practice Address - Street 2:
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91739-2215
Practice Address - Country:US
Practice Address - Phone:909-268-2126
Practice Address - Fax:909-899-8850
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-10
Last Update Date:2007-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARN290090163WR0006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WR0006XNursing Service ProvidersRegistered NurseRegistered Nurse First Assistant