Provider Demographics
NPI:1629642624
Name:LACKEY, CARISSA M (MD, MPH)
Entity type:Individual
Prefix:
First Name:CARISSA
Middle Name:M
Last Name:LACKEY
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Gender:F
Credentials:MD, MPH
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Mailing Address - Street 1:100 PARK STREET
Mailing Address - Street 2:GLENS FALLS HOSPITAL - CREDENTIALING
Mailing Address - City:GLENS FALLS
Mailing Address - State:NY
Mailing Address - Zip Code:12801-4413
Mailing Address - Country:US
Mailing Address - Phone:518-926-5924
Mailing Address - Fax:518-926-6983
Practice Address - Street 1:35 GILBERT STREET
Practice Address - Street 2:CAMBRIDGE MEDICAL CENTER
Practice Address - City:CAMBRIDGE
Practice Address - State:NY
Practice Address - Zip Code:12816-2618
Practice Address - Country:US
Practice Address - Phone:518-677-3961
Practice Address - Fax:518-677-3180
Is Sole Proprietor?:No
Enumeration Date:2021-05-14
Last Update Date:2024-09-24
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Provider Licenses
StateLicense IDTaxonomies
NY332725207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine