Healthcare Provider Details

I. General information

NPI: 1922414044
Provider Name (Legal Business Name): EDNA DENISE LACKEY RN MBA PH.D
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/09/2014
Last Update Date: 07/16/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11260 CHESTER RD 240
CINCINNATI OH
45246-4048
US

IV. Provider business mailing address

11260 CHESTER RD 240
CINCINNATI OH
45246-4048
US

V. Phone/Fax

Practice location:
  • Phone: 513-771-3412
  • Fax: 513-771-1167
Mailing address:
  • Phone: 513-771-3412
  • Fax: 513-771-1167

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code101YP1600X
TaxonomyPastoral Counselor
License Number
License Number StateOH
# 3
Primary TaxonomyY
Taxonomy Code163WA2000X
TaxonomyAdministrator Registered Nurse
License NumberRN-257326
License Number StateOH
# 4
Primary TaxonomyN
Taxonomy Code163WD0400X
TaxonomyDiabetes Educator Registered Nurse
License NumberRN-257326
License Number StateOH
# 5
Primary TaxonomyN
Taxonomy Code174H00000X
TaxonomyHealth Educator
License NumberRN-257326
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: