Provider Demographics
NPI:1184948424
Name:LACKEY, KELLY CORINNE
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:CORINNE
Last Name:LACKEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:CORINNE
Other - Last Name:DUNAWAY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4148 OXFORD MIDDLETOWN RD
Mailing Address - Street 2:
Mailing Address - City:TRENTON
Mailing Address - State:OH
Mailing Address - Zip Code:45067-9693
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4148 OXFORD MIDDLETOWN RD
Practice Address - Street 2:
Practice Address - City:TRENTON
Practice Address - State:OH
Practice Address - Zip Code:45067-9693
Practice Address - Country:US
Practice Address - Phone:513-312-1935
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-16
Last Update Date:2019-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPN093691164W00000X
OH093691164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK16Medicaid
OH1184948424Medicaid