Provider Demographics
NPI:1104122647
Name:LACKEY, LISA RENEE (APRN)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:RENEE
Last Name:LACKEY
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:RENEE
Other - Last Name:LACKEY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:RN NP-BC
Mailing Address - Street 1:6701 JEFFERSON ST NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87109-4318
Mailing Address - Country:US
Mailing Address - Phone:505-727-6200
Mailing Address - Fax:
Practice Address - Street 1:6701 JEFFERSON ST NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87109-4318
Practice Address - Country:US
Practice Address - Phone:505-727-6200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-01
Last Update Date:2024-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV818418363L00000X
NMCNP-01735363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMCNP-01735OtherNM LICENSE