Provider Demographics
NPI:1396394144
Name:LACKEY, BRYCE C
Entity Type:Individual
Prefix:
First Name:BRYCE
Middle Name:C
Last Name:LACKEY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:158 FESS LITTLE RD
Mailing Address - Street 2:
Mailing Address - City:TAYLORSVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28681-6651
Mailing Address - Country:US
Mailing Address - Phone:704-437-1533
Mailing Address - Fax:
Practice Address - Street 1:321 MULBERRY ST SW
Practice Address - Street 2:
Practice Address - City:LENOIR
Practice Address - State:NC
Practice Address - Zip Code:28645-5720
Practice Address - Country:US
Practice Address - Phone:828-757-5100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-04
Last Update Date:2022-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC6224367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered