Provider Demographics
NPI:1750189064
Name:LUCKETT, MADISON ELAINE
Entity type:Individual
Prefix:MISS
First Name:MADISON
Middle Name:ELAINE
Last Name:LUCKETT
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6071 RIDGE RUN DR NW
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:OH
Mailing Address - Zip Code:44481-9022
Mailing Address - Country:US
Mailing Address - Phone:330-240-7158
Mailing Address - Fax:
Practice Address - Street 1:6071 RIDGE RUN DR NW
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:OH
Practice Address - Zip Code:44481-9022
Practice Address - Country:US
Practice Address - Phone:330-240-7158
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-03-04
Last Update Date:2025-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer