Provider Demographics
NPI:1790025369
Name:LACKEY, DEBORAH DELORES
Entity Type:Individual
Prefix:MS
First Name:DEBORAH
Middle Name:DELORES
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 1:1346 LINCOLN AVE
Mailing Address - Street 2:
Mailing Address - City:CINCINNAN
Mailing Address - State:OH
Mailing Address - Zip Code:45206
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1346 LINCOLN AVE
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45206
Practice Address - Country:US
Practice Address - Phone:513-861-2044
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-02-19
Last Update Date:2013-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPN087437-M-IV164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse