Provider Demographics
NPI:1942341615
Name:LACKEY, DIANA LYNN (MD)
Entity Type:Individual
Prefix:
First Name:DIANA
Middle Name:LYNN
Last Name:LACKEY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 909
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40201-0909
Mailing Address - Country:US
Mailing Address - Phone:502-587-4267
Mailing Address - Fax:
Practice Address - Street 1:201 ABRAHAM FLEXNER WAY STE 905
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40202-3803
Practice Address - Country:US
Practice Address - Phone:502-587-4267
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-08
Last Update Date:2024-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA33011174400000X
IN01064153A174400000X, 207R00000X
KYTP230207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200874290Medicaid
KY7100657170Medicaid
IN256840024OtherMEDICARE PTAN
GA29BDBXCMedicare PIN
IN200874290Medicaid