Provider Demographics
NPI:1629309463
Name:LACKIE, CATHERINE TALBOT (FNP)
Entity Type:Individual
Prefix:
First Name:CATHERINE
Middle Name:TALBOT
Last Name:LACKIE
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:CATHERINE
Other - Middle Name:PAGE
Other - Last Name:TALBOT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FNP
Mailing Address - Street 1:6077 PRIMACY PKWY STE 140
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38119-5742
Mailing Address - Country:US
Mailing Address - Phone:901-725-8347
Mailing Address - Fax:901-259-7637
Practice Address - Street 1:6286 BRIARCREST AVE STE 200
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38120-4023
Practice Address - Country:US
Practice Address - Phone:901-641-3000
Practice Address - Fax:901-259-1698
Is Sole Proprietor?:No
Enumeration Date:2010-01-19
Last Update Date:2021-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN168742163W00000X
TN14930363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3371161Medicaid
TN4306810OtherBCBS TN
MS620819926OtherBCBS MS
TN620819926OtherAETNA
MS7187860Medicaid
AR110318002Medicaid
TN9337653OtherAETNA
TN0723280001Medicare NSC
TN10350I5126Medicare PIN