Provider Demographics
NPI:1205649613
Name:LUCKEY, KIMBERLEY (PTA)
Entity type:Individual
Prefix:MRS
First Name:KIMBERLEY
Middle Name:
Last Name:LUCKEY
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:326 PARSLEY BLVD
Mailing Address - Street 2:
Mailing Address - City:CHEYENNE
Mailing Address - State:WY
Mailing Address - Zip Code:82007-1014
Mailing Address - Country:US
Mailing Address - Phone:307-632-2991
Mailing Address - Fax:
Practice Address - Street 1:326 PARSLEY BLVD
Practice Address - Street 2:
Practice Address - City:CHEYENNE
Practice Address - State:WY
Practice Address - Zip Code:82007-1014
Practice Address - Country:US
Practice Address - Phone:307-632-2991
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-01-29
Last Update Date:2025-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY0773225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant