Healthcare Provider Details

I. General information

NPI: 1093511982
Provider Name (Legal Business Name): MALLORY JEAN LACKEY FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/20/2025
Last Update Date: 05/07/2026
Certification Date: 05/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1620 PRESIDENT AVE
FALL RIVER MA
02720-7148
US

IV. Provider business mailing address

546 SOUTH ST E
RAYNHAM MA
02767-1079
US

V. Phone/Fax

Practice location:
  • Phone: 508-672-2403
  • Fax:
Mailing address:
  • Phone: 508-821-5700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRN2352059
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN2352059
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: