Provider Demographics
NPI:1245469840
Name:LACKEY, KRISTEN ELIZABETH (LMT)
Entity type:Individual
Prefix:MS
First Name:KRISTEN
Middle Name:ELIZABETH
Last Name:LACKEY
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:MS
Other - First Name:KRISTEN
Other - Middle Name:ELIZABETH
Other - Last Name:LENOVER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMT
Mailing Address - Street 1:1705 E HIGHWAY 50
Mailing Address - Street 2:SUITE B
Mailing Address - City:CLERMONT
Mailing Address - State:FL
Mailing Address - Zip Code:34711-5186
Mailing Address - Country:US
Mailing Address - Phone:352-394-7577
Mailing Address - Fax:352-394-8000
Practice Address - Street 1:1705 E HIGHWAY 50
Practice Address - Street 2:SUITE B
Practice Address - City:CLERMONT
Practice Address - State:FL
Practice Address - Zip Code:34711-5186
Practice Address - Country:US
Practice Address - Phone:352-394-7577
Practice Address - Fax:352-394-8000
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-06
Last Update Date:2009-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA53008225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist