Provider Demographics
NPI:1205403151
Name:LACKEY, JAMES DYLAN (FNP-BC)
Entity Type:Individual
Prefix:MR
First Name:JAMES
Middle Name:DYLAN
Last Name:LACKEY
Suffix:
Gender:M
Credentials:FNP-BC
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Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:4940 GOVERNORS DR STE 209
Mailing Address - Street 2:
Mailing Address - City:FOREST PARK
Mailing Address - State:GA
Mailing Address - Zip Code:30297-2186
Mailing Address - Country:US
Mailing Address - Phone:770-277-1290
Mailing Address - Fax:770-277-0282
Practice Address - Street 1:4940 GOVERNORS DR STE 209
Practice Address - Street 2:
Practice Address - City:FOREST PARK
Practice Address - State:GA
Practice Address - Zip Code:30297-2186
Practice Address - Country:US
Practice Address - Phone:770-277-1290
Practice Address - Fax:770-277-0282
Is Sole Proprietor?:No
Enumeration Date:2021-06-09
Last Update Date:2021-06-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GARN282621363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily