Basic Information
| Provider Information | |||||||||
| NPI: | 1003858150 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LUCKEY | ||||||||
| FirstName: | CAROL | ||||||||
| MiddleName: | R | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | P.O BOX 11567 | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | TN | ||||||||
| PostalCode: | 38308 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7316610086 | ||||||||
| FaxNumber: | 7316609055 | ||||||||
| Practice Location | |||||||||
| Address1: | 120 E CHURCH ST | ||||||||
| Address2: | |||||||||
| City: | LEXINGTON | ||||||||
| State: | TN | ||||||||
| PostalCode: | 38351 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7319680146 | ||||||||
| FaxNumber: | 7319689398 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/12/2006 | ||||||||
| LastUpdateDate: | 10/12/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP2300X | APN0000005691 | TN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Primary Care | 363L00000X | APN5691 | TN | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 0000000031363 | 01 | TN | MEMPHIS MANAGED CARE (TLC | OTHER | 156102 | 01 | TN | UNISON | OTHER | 39006861 | 05 | TN | MEDICAID | 4157526 | 01 | BLUE CROSS BLUE SHIELD TN | OTHER | 3900686 | 05 | TN | MEDICAID | 4083540 | 01 | TN | TN CARE SELECT | OTHER | 4083540 | 01 | TN | BLUE CROSS BLUE SHIELD TN | OTHER |