Provider Demographics
NPI:1205904174
Name:LACKEY, THOMAS BRITT (ENP)
Entity type:Individual
Prefix:MR
First Name:THOMAS
Middle Name:BRITT
Last Name:LACKEY
Suffix:
Gender:M
Credentials:ENP
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 7714
Mailing Address - Street 2:
Mailing Address - City:BEAUMONT
Mailing Address - State:TX
Mailing Address - Zip Code:77726-7714
Mailing Address - Country:US
Mailing Address - Phone:409-893-1177
Mailing Address - Fax:
Practice Address - Street 1:655 S MAIN ST
Practice Address - Street 2:
Practice Address - City:LUMBERTON
Practice Address - State:TX
Practice Address - Zip Code:77657-7378
Practice Address - Country:US
Practice Address - Phone:409-227-4084
Practice Address - Fax:409-227-4140
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-01
Last Update Date:2022-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX261QU0200X
TX641335363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care