Provider Demographics
NPI:1154189074
Name:LUCKETT, CANDACE M
Entity type:Individual
Prefix:
First Name:CANDACE
Middle Name:M
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 1:17800 TALBOT RD S STE 108
Mailing Address - Street 2:
Mailing Address - City:RENTON
Mailing Address - State:WA
Mailing Address - Zip Code:98055-5764
Mailing Address - Country:US
Mailing Address - Phone:206-271-8581
Mailing Address - Fax:
Practice Address - Street 1:17800 TALBOT RD S STE 108
Practice Address - Street 2:
Practice Address - City:RENTON
Practice Address - State:WA
Practice Address - Zip Code:98055-5764
Practice Address - Country:US
Practice Address - Phone:206-271-8581
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-03-06
Last Update Date:2024-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1744P3200XOther Service ProvidersSpecialistProsthetics Case Management