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General NPI Number Information
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NPI Number | 1770290314
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Entity Type | Individual
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Provider Name | BRIAN LACKEY NP
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Gender | Male
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Dates
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Enumeration Date | 11/02/2022
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Last Update Date | 11/02/2022
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Provider Practice Location Address
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Address Line | 800 TILGHMAN DR
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City | DUNN
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State | NC
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Zip | 28334-5510
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Country | US
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Telephone | 919-461-0017
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Fax |
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Provider Business Mailing Address
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Address Line | 62 PAULA DR
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City | ANGIER
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State | NC
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Zip | 27501-9029
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Country | US
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Telephone | 910-494-0018
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363L00000X
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Taxonomy Name | Nurse Practitioner
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License Number | LACK-V9WF0
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License Number State | NC
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Taxonomy #2
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Taxonomy Code | 163W00000X
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Taxonomy Name | Registered Nurse
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License Number | 249344
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License Number State | NC
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