Provider Demographics
NPI:1780922849
Name:LACKEY, RACHAEL CLARK (ARNP)
Entity type:Individual
Prefix:
First Name:RACHAEL
Middle Name:CLARK
Last Name:LACKEY
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:454 SMITH AVE
Mailing Address - Street 2:
Mailing Address - City:THOMASVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:31792-5535
Mailing Address - Country:US
Mailing Address - Phone:229-584-2540
Mailing Address - Fax:229-226-2036
Practice Address - Street 1:4681 US HIGHWAY 84 BYP W
Practice Address - Street 2:
Practice Address - City:THOMASVILLE
Practice Address - State:GA
Practice Address - Zip Code:31792-2607
Practice Address - Country:US
Practice Address - Phone:229-227-2936
Practice Address - Fax:229-226-2036
Is Sole Proprietor?:No
Enumeration Date:2013-01-24
Last Update Date:2017-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP9297951363LP0200X
GARN224594363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLARNP9297951OtherFLORIDA DEPARTMENT OF HEALTH
GARN224594OtherGA LICENSE