| Doctor Name: | LISA RENEE LACKEY |
| NPI Number: | 1104122647 |
| Entity Type Code: | Individual (1) |
| Gender: | F |
| Credentials: | RN NP-BC |
| License Number: | CNP-01735 |
| Business Practice Address: | 1423 E Roosevelt Ave Grants, NM - 870202245 |
| Business Phone Number: | 5052876500 |
| Business Fax Number: | |
| Mailing Address: | 1423 E Roosevelt Ave, GRANTS |
| State: | NM |
| Postal Code: | 870202245 |
| Phone Number: | 5052876500 |
| Fax Number: | |
| NPI Enumeration Date: | 02/01/2011 |
| NPI Last Update Date: | 05/19/2014 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 363LF0000X |
| License Number: | CNP-01735 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | NM |
| Taxonomy Type: | Physician Assistants & Advanced Practice Nursing Providers |
| Taxonomy Classification: | Nurse Practitioner |
| Taxonomy Specialization: | Family |
| Taxonomy Definition: | |