Provider Demographics
NPI:1871181990
Name:LUCKEY, NICOLE ELIZABETH (LMT, EMT)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:ELIZABETH
Last Name:LUCKEY
Suffix:
Gender:F
Credentials:LMT, EMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:44 FOREST RD
Mailing Address - Street 2:
Mailing Address - City:COVENTRY
Mailing Address - State:CT
Mailing Address - Zip Code:06238-2920
Mailing Address - Country:US
Mailing Address - Phone:860-377-4413
Mailing Address - Fax:
Practice Address - Street 1:44 FOREST RD
Practice Address - Street 2:
Practice Address - City:COVENTRY
Practice Address - State:CT
Practice Address - Zip Code:06238-2920
Practice Address - Country:US
Practice Address - Phone:860-377-4413
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-05
Last Update Date:2021-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT10726225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist