Provider Demographics
NPI:1447983689
Name:LUCKETT, MELISSA WHITFIELD (FNP)
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:WHITFIELD
Last Name:LUCKETT
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:460 CLEMSON RD
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29229-7925
Mailing Address - Country:US
Mailing Address - Phone:803-438-3800
Mailing Address - Fax:803-438-3898
Practice Address - Street 1:1333 TAYLOR ST STE 2D
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29201-2945
Practice Address - Country:US
Practice Address - Phone:803-438-3800
Practice Address - Fax:803-438-3898
Is Sole Proprietor?:No
Enumeration Date:2022-07-06
Last Update Date:2022-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC26227207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine