MEDICARE: SHAZIA LACKEY APRN, CPNP-PC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LP0200X	Pediatric Nurse Practitioner	AP143474	TX

General Provider Information

NPI Number	:	1083257398
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHAZIA LACKEY APRN, CPNP-PC

Provider Business Mailing Address
First Line	:	2104 COOLIDGE DR
Second Line	:
City	:	ARLINGTON
State	:	TX
Zip	:	76011-3206
Country	:	US
Telephone Number	:	817-312-3396
Fax Number	:

Provider Business Practice Location Address
First Line	:	4120 N COLLINS ST STE 200
Second Line	:
City	:	ARLINGTON
State	:	TX
Zip	:	76005-4554
Country	:	US
Telephone Number	:	817-372-2283
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/21/2019
Last Update Date	:	01/27/2020

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