Provider Demographics
NPI:1730118431
Name:DILLON, NICOLE LACKEY (MD)
Entity Type:Individual
Prefix:MRS
First Name:NICOLE
Middle Name:LACKEY
Last Name:DILLON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:MRS
Other - First Name:NICOLE
Other - Middle Name:
Other - Last Name:LACKEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:20 HOSPITAL DR
Mailing Address - Street 2:
Mailing Address - City:LOGAN
Mailing Address - State:WV
Mailing Address - Zip Code:25601-3452
Mailing Address - Country:US
Mailing Address - Phone:304-831-1825
Mailing Address - Fax:304-831-1828
Practice Address - Street 1:77 HOSPITAL DR STE D
Practice Address - Street 2:
Practice Address - City:LOGAN
Practice Address - State:WV
Practice Address - Zip Code:25601-3451
Practice Address - Country:US
Practice Address - Phone:304-752-9290
Practice Address - Fax:304-896-8682
Is Sole Proprietor?:No
Enumeration Date:2006-07-03
Last Update Date:2022-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY39860207Q00000X
WV21324207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV1810172000Medicaid
H93529Medicare UPIN
P00286393Medicare ID - Type UnspecifiedRAIL ROAD MEDICARE
LA7366381Medicare PIN
KY0307660Medicare ID - Type Unspecified