Provider Demographics
NPI:1972851509
Name:LACKEY, CANISHA N
Entity Type:Individual
Prefix:MS
First Name:CANISHA
Middle Name:N
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 1:3825 KIRKUP AVE
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45213-1921
Mailing Address - Country:US
Mailing Address - Phone:513-344-5495
Mailing Address - Fax:
Practice Address - Street 1:3825 KIRKUP AVE
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45213-1921
Practice Address - Country:US
Practice Address - Phone:513-344-5495
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-29
Last Update Date:2012-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide