Provider Demographics
NPI:1063223626
Name:LUCKETT, LAKESHA
Entity type:Individual
Prefix:
First Name:LAKESHA
Middle Name:
Last Name:LUCKETT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2330 E CHESTNUT DR
Mailing Address - Street 2:
Mailing Address - City:OAK CREEK
Mailing Address - State:WI
Mailing Address - Zip Code:53154-1614
Mailing Address - Country:US
Mailing Address - Phone:414-397-2528
Mailing Address - Fax:
Practice Address - Street 1:2330 E CHESTNUT DR
Practice Address - Street 2:
Practice Address - City:OAK CREEK
Practice Address - State:WI
Practice Address - Zip Code:53154-1614
Practice Address - Country:US
Practice Address - Phone:414-397-2528
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-01-14
Last Update Date:2025-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI0020376207QA0505X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult Medicine