Basic Information
Provider Information | |||||||||
NPI: | 1629309463 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | LACKIE | ||||||||
FirstName: | CATHERINE | ||||||||
MiddleName: | TALBOT | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | FNP | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | TALBOT | ||||||||
OtherFirstName: | CATHERINE | ||||||||
OtherMiddleName: | PAGE | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | FNP | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 6077 PRIMACY PKWY STE 140 | ||||||||
Address2: |   | ||||||||
City: | MEMPHIS | ||||||||
State: | TN | ||||||||
PostalCode: | 381195742 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9017258347 | ||||||||
FaxNumber: | 9012597637 | ||||||||
Practice Location | |||||||||
Address1: | 6286 BRIARCREST AVE STE 200 | ||||||||
Address2: |   | ||||||||
City: | MEMPHIS | ||||||||
State: | TN | ||||||||
PostalCode: | 381204023 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9016413000 | ||||||||
FaxNumber: | 9012591698 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/19/2010 | ||||||||
LastUpdateDate: | 03/18/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 03/18/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 168742 | TN | N |   | Nursing Service Providers | Registered Nurse |   | 363LF0000X | 14930 | TN | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
ID | Type | State | Issuer | Description | 3371161 | 05 | TN |   | MEDICAID | 4306810 | 01 | TN | BCBS TN | OTHER | 620819926 | 01 | MS | BCBS MS | OTHER | 620819926 | 01 | TN | AETNA | OTHER | 7187860 | 05 | MS |   | MEDICAID | 110318002 | 05 | AR |   | MEDICAID | 9337653 | 01 | TN | AETNA | OTHER |