Provider Demographics
NPI:1770290314
Name:LACKEY, BRIAN (NP)
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:
Last Name:LACKEY
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:62 PAULA DR
Mailing Address - Street 2:
Mailing Address - City:ANGIER
Mailing Address - State:NC
Mailing Address - Zip Code:27501-9029
Mailing Address - Country:US
Mailing Address - Phone:910-494-0018
Mailing Address - Fax:
Practice Address - Street 1:800 TILGHMAN DR
Practice Address - Street 2:
Practice Address - City:DUNN
Practice Address - State:NC
Practice Address - Zip Code:28334-5510
Practice Address - Country:US
Practice Address - Phone:919-461-0017
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-11-02
Last Update Date:2022-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC249344163W00000X
NCLACK-V9WF0363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse