Provider Demographics
NPI:1588661292
Name:LACKEY, AMY (OD)
Entity Type:Individual
Prefix:DR
First Name:AMY
Middle Name:
Last Name:LACKEY
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:60 RICHARD DR
Mailing Address - Street 2:
Mailing Address - City:RINGGOLD
Mailing Address - State:GA
Mailing Address - Zip Code:30736-8253
Mailing Address - Country:US
Mailing Address - Phone:429-892-4900
Mailing Address - Fax:
Practice Address - Street 1:6940 LEE HWY
Practice Address - Street 2:SUITE 108
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37421-2490
Practice Address - Country:US
Practice Address - Phone:423-892-4900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-07
Last Update Date:2019-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNOD1227152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN4016638OtherBCBS
TN4016638OtherBCBS
TN3599723Medicare ID - Type Unspecified