Provider Demographics
NPI:1417257486
Name:LACKEY, MELISSA LYNN
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:LYNN
Last Name:LACKEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 THE CITY DRIVE SOUTH
Mailing Address - Street 2:
Mailing Address - City:ORANGE
Mailing Address - State:CA
Mailing Address - Zip Code:92868
Mailing Address - Country:US
Mailing Address - Phone:714-456-2986
Mailing Address - Fax:714-456-2979
Practice Address - Street 1:101 THE CITY DR S
Practice Address - Street 2:
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92868-3201
Practice Address - Country:US
Practice Address - Phone:714-456-2986
Practice Address - Fax:714-456-2979
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-25
Last Update Date:2010-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA3841492171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor