Provider Demographics
NPI:1922414044
Name:LACKEY, EDNA DENISE (RN MBA PHD)
Entity Type:Individual
Prefix:DR
First Name:EDNA
Middle Name:DENISE
Last Name:LACKEY
Suffix:
Gender:F
Credentials:RN MBA PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11260 CHESTER RD
Mailing Address - Street 2:240
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45246-4048
Mailing Address - Country:US
Mailing Address - Phone:513-771-3412
Mailing Address - Fax:513-771-1167
Practice Address - Street 1:11260 CHESTER RD
Practice Address - Street 2:240
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45246-4048
Practice Address - Country:US
Practice Address - Phone:513-771-3412
Practice Address - Fax:513-771-1167
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-09
Last Update Date:2014-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA101YM0800X
OH101YP1600X
OHRN-257326163WA2000X, 163WD0400X, 174H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WA2000XNursing Service ProvidersRegistered NurseAdministrator
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoral
No163WD0400XNursing Service ProvidersRegistered NurseDiabetes Educator
No174H00000XOther Service ProvidersHealth Educator