Provider Demographics
NPI:1588664262
Name:LACKEY, ANDREA LYNN-NIELSON (DC)
Entity type:Individual
Prefix:
First Name:ANDREA
Middle Name:LYNN-NIELSON
Last Name:LACKEY
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30 W SHERMAN ST
Mailing Address - Street 2:
Mailing Address - City:HUTCHINSON
Mailing Address - State:KS
Mailing Address - Zip Code:67501-5428
Mailing Address - Country:US
Mailing Address - Phone:620-663-5632
Mailing Address - Fax:620-663-4986
Practice Address - Street 1:30 W SHERMAN ST
Practice Address - Street 2:
Practice Address - City:HUTCHINSON
Practice Address - State:KS
Practice Address - Zip Code:67501-5428
Practice Address - Country:US
Practice Address - Phone:620-663-5632
Practice Address - Fax:620-663-4986
Is Sole Proprietor?:No
Enumeration Date:2005-07-26
Last Update Date:2011-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS4340111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS055008OtherBCBS
U60950Medicare UPIN
KS055008Medicare ID - Type Unspecified