Provider Demographics
NPI:1548755432
Name:LACKEY, DANIEL JAMES (NP)
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:JAMES
Last Name:LACKEY
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 360
Mailing Address - Street 2:
Mailing Address - City:SYLVA
Mailing Address - State:NC
Mailing Address - Zip Code:28779-0360
Mailing Address - Country:US
Mailing Address - Phone:888-339-6065
Mailing Address - Fax:828-538-4441
Practice Address - Street 1:1287 CREEKSHIRE WAY
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-3057
Practice Address - Country:US
Practice Address - Phone:336-245-9521
Practice Address - Fax:855-308-2340
Is Sole Proprietor?:No
Enumeration Date:2018-06-25
Last Update Date:2023-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5010621363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCQ00092508OtherRAILROAD MEDICARE
NC1548755432Medicaid
NC19YVPOtherBCBS NC
NCNNG668AOtherMEDICARE