Provider Demographics
NPI:1639795131
Name:LACKEY, SATIVA (FNP-C)
Entity type:Individual
Prefix:
First Name:SATIVA
Middle Name:
Last Name:LACKEY
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:113 S THOMAS CV
Mailing Address - Street 2:
Mailing Address - City:BURNET
Mailing Address - State:TX
Mailing Address - Zip Code:78611-2086
Mailing Address - Country:US
Mailing Address - Phone:512-944-6548
Mailing Address - Fax:
Practice Address - Street 1:4303 VICTORY DR
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78704-7507
Practice Address - Country:US
Practice Address - Phone:512-462-3627
Practice Address - Fax:512-462-2898
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-19
Last Update Date:2024-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP143975363LF0000X, 363L00000X
TX692669363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty