Provider Demographics
NPI:1558974279
Name:LACKEY, BRENDA KAY
Entity Type:Individual
Prefix:
First Name:BRENDA
Middle Name:KAY
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 1:208 CREEKSIDE DR
Mailing Address - Street 2:
Mailing Address - City:LENORE
Mailing Address - State:WV
Mailing Address - Zip Code:25676-7066
Mailing Address - Country:US
Mailing Address - Phone:304-475-2018
Mailing Address - Fax:
Practice Address - Street 1:208 CREEKSIDE DR
Practice Address - Street 2:
Practice Address - City:LENORE
Practice Address - State:WV
Practice Address - Zip Code:25676-7066
Practice Address - Country:US
Practice Address - Phone:304-475-2018
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-24
Last Update Date:2021-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant