Provider Demographics
NPI:1740013341
Name:LACKEY, KENEDI ALEXUS (PT, DPT)
Entity type:Individual
Prefix:
First Name:KENEDI
Middle Name:ALEXUS
Last Name:LACKEY
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7985 KNIGHT RD
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30506-6427
Mailing Address - Country:US
Mailing Address - Phone:770-781-4899
Mailing Address - Fax:
Practice Address - Street 1:7985 KNIGHT RD
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:GA
Practice Address - Zip Code:30506-6427
Practice Address - Country:US
Practice Address - Phone:770-781-4899
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-21
Last Update Date:2024-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT017294225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty