Provider Demographics
NPI:1710126966
Name:LUCKETT, CAROLYN M (NP)
Entity Type:Individual
Prefix:MS
First Name:CAROLYN
Middle Name:M
Last Name:LUCKETT
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 1:127 S 500 E STE 600
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84102-1971
Mailing Address - Country:US
Mailing Address - Phone:801-587-6705
Mailing Address - Fax:801-715-8228
Practice Address - Street 1:2000 CIRCLE OF HOPE DR
Practice Address - Street 2:CLINIC 2D
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84112-5550
Practice Address - Country:US
Practice Address - Phone:801-585-0100
Practice Address - Fax:801-581-7381
Is Sole Proprietor?:Yes
Enumeration Date:2009-02-11
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT220048-4405363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily