Provider Demographics
NPI:1275186892
Name:LACKEY, ANNABEL MARRUFO (AGNP)
Entity Type:Individual
Prefix:
First Name:ANNABEL
Middle Name:MARRUFO
Last Name:LACKEY
Suffix:
Gender:F
Credentials:AGNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3834 S EMERSON AVE
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46203-5901
Mailing Address - Country:US
Mailing Address - Phone:317-781-2009
Mailing Address - Fax:
Practice Address - Street 1:3834 S EMERSON AVE
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46203-5901
Practice Address - Country:US
Practice Address - Phone:317-781-2009
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-23
Last Update Date:2021-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28163199A163W00000X
IN71009680A363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
No163W00000XNursing Service ProvidersRegistered Nurse