Provider Demographics
NPI:1083257398
Name:LACKEY, SHAZIA (APRN, CPNP-PC)
Entity Type:Individual
Prefix:
First Name:SHAZIA
Middle Name:
Last Name:LACKEY
Suffix:
Gender:F
Credentials:APRN, CPNP-PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2104 COOLIDGE DR
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:TX
Mailing Address - Zip Code:76011-3206
Mailing Address - Country:US
Mailing Address - Phone:817-312-3396
Mailing Address - Fax:
Practice Address - Street 1:4120 N COLLINS ST STE 200
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:TX
Practice Address - Zip Code:76005-4554
Practice Address - Country:US
Practice Address - Phone:817-372-2283
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-21
Last Update Date:2020-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP143474363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics