Healthcare Provider Details

I. General information

NPI: 1679847487
Provider Name (Legal Business Name): ASHLEY COBY LACKEY CRNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ASHLEY COBY

II. Dates (important events)

Enumeration Date: 02/27/2012
Last Update Date: 05/19/2022
Certification Date: 05/19/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19707 US HIGHWAY 280 E APT 1309
SMITHS STATION AL
36877-4031
US

IV. Provider business mailing address

2986 US HIGHWAY 431
BOAZ AL
35957-5848
US

V. Phone/Fax

Practice location:
  • Phone: 256-572-5936
  • Fax:
Mailing address:
  • Phone: 256-572-5936
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number1-122189
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: