Provider Demographics
NPI:1922068022
Name:LACKNER, CONSTANCE SUE (MSN APRN BC)
Entity Type:Individual
Prefix:MRS
First Name:CONSTANCE
Middle Name:SUE
Last Name:LACKNER
Suffix:
Gender:F
Credentials:MSN APRN BC
Other - Prefix:MISS
Other - First Name:CONSTANCE
Other - Middle Name:SUE
Other - Last Name:LACKNER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSN APRN BC
Mailing Address - Street 1:1167 SPRATLIN PARK DR
Mailing Address - Street 2:
Mailing Address - City:GRAY
Mailing Address - State:TN
Mailing Address - Zip Code:37615-6205
Mailing Address - Country:US
Mailing Address - Phone:423-467-3600
Mailing Address - Fax:423-467-3644
Practice Address - Street 1:109 W WATAUGA AVE
Practice Address - Street 2:
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37604-5621
Practice Address - Country:US
Practice Address - Phone:423-232-2600
Practice Address - Fax:423-467-3644
Is Sole Proprietor?:No
Enumeration Date:2006-03-24
Last Update Date:2023-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNAPN07278363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3143910OtherBLUE CROSS BLUE SHIELD
TN3345085Medicaid
890000552OtherRAILROAD PROVIDER
TN3345085Medicaid
890000552OtherRAILROAD PROVIDER