Provider Demographics
NPI:1407400666
Name:LACKEY, HOLLY MARIE (RN)
Entity Type:Individual
Prefix:
First Name:HOLLY
Middle Name:MARIE
Last Name:LACKEY
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 422
Mailing Address - Street 2:
Mailing Address - City:BEN WHEELER
Mailing Address - State:TX
Mailing Address - Zip Code:75754-0422
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:176 VZCR 4714
Practice Address - Street 2:
Practice Address - City:BEN WHEELER
Practice Address - State:TX
Practice Address - Zip Code:75754-0422
Practice Address - Country:US
Practice Address - Phone:903-279-6547
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-26
Last Update Date:2019-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX795338163WP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0200XNursing Service ProvidersRegistered NursePediatrics