Healthcare Provider Details

I. General information

NPI: 1760421663
Provider Name (Legal Business Name): VICKI LACKEY ANP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/06/2006
Last Update Date: 10/03/2022
Certification Date: 10/03/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1950 45TH ST STE 200
MUNSTER IN
46321-3958
US

IV. Provider business mailing address

1950 45TH ST STE 200
MUNSTER IN
46321-3958
US

V. Phone/Fax

Practice location:
  • Phone: 219-912-3376
  • Fax: 219-529-6267
Mailing address:
  • Phone: 219-912-3376
  • Fax: 219-529-6267

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number71001103
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: