MEDICARE: MRS. NICOLE LACKEY DILLON MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	39860	KY
2	207Q00000X	Family Medicine Physician	21324	WV

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1730118431
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. NICOLE LACKEY DILLON MD

Provider Business Mailing Address
First Line	:	20 HOSPITAL DR
Second Line	:
City	:	LOGAN
State	:	WV
Zip	:	25601-3452
Country	:	US
Telephone Number	:	304-831-1825
Fax Number	:	304-831-1828

Provider Business Practice Location Address
First Line	:	77 HOSPITAL DR STE D
Second Line	:
City	:	LOGAN
State	:	WV
Zip	:	25601-3451
Country	:	US
Telephone Number	:	304-752-9290
Fax Number	:	304-896-8682

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/03/2006
Last Update Date	:	08/18/2022

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