Provider Demographics
NPI:1912090770
Name:LACKEY, BRIAN MITCHEL (RN)
Entity Type:Individual
Prefix:MR
First Name:BRIAN
Middle Name:MITCHEL
Last Name:LACKEY
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:991 WEST HUDSON BLVD
Mailing Address - Street 2:
Mailing Address - City:GASTONIA
Mailing Address - State:NC
Mailing Address - Zip Code:28052
Mailing Address - Country:US
Mailing Address - Phone:704-853-5083
Mailing Address - Fax:704-853-5240
Practice Address - Street 1:991 WEST HUDSON BLVD
Practice Address - Street 2:
Practice Address - City:GASTONIA
Practice Address - State:NC
Practice Address - Zip Code:28052
Practice Address - Country:US
Practice Address - Phone:704-853-5083
Practice Address - Fax:704-853-5240
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC138742163WC1500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC1500XNursing Service ProvidersRegistered NurseCommunity Health