Provider Demographics
NPI:1770932170
Name:LUCKEY, MALLORY NOELLE (MD)
Entity type:Individual
Prefix:
First Name:MALLORY
Middle Name:NOELLE
Last Name:LUCKEY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:640 PUDDINGSTONE PKWY
Mailing Address - Street 2:
Mailing Address - City:BANNER ELK
Mailing Address - State:NC
Mailing Address - Zip Code:28604-7418
Mailing Address - Country:US
Mailing Address - Phone:864-237-4021
Mailing Address - Fax:864-778-8417
Practice Address - Street 1:640 PUDDINGSTONE PKWY
Practice Address - Street 2:
Practice Address - City:BANNER ELK
Practice Address - State:NC
Practice Address - Zip Code:28604-7418
Practice Address - Country:US
Practice Address - Phone:864-237-4021
Practice Address - Fax:864-778-8417
Is Sole Proprietor?:No
Enumeration Date:2016-06-07
Last Update Date:2024-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2022-012712084N0400X
FLME1590602084N0400X
MO20230069732084N0400X
ORMD2141782084N0400X
SCLL39661207R00000X
NY3026092084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine