# NICOLE LACKEY DILLON, MD, INC

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- **Entity:** Organization
- **Status:** Active
- **Other names:** Grayson Family Medicine
- **Organization subpart:** No

## Provider details

- **NPI number:** 1396092508
- **Authorized official:** DR. NICOLE LACKEY DILLON M.D. (PRESIDENT)
- **Authorized official phone:** (304) 752-9290

## Contact information

- **Practice address:** 77 HOSPITAL DR, DOCTORS PARK SUITE D, LOGAN, WV 25601-3451
- **Practice address phone:** (304) 752-9290
- **Mailing address:** 77 HOSPITAL DR STE D, LOGAN, WV 25601-3451
- **Mailing address phone:** (304) 752-9290
- **Mailing address fax:** (304) 896-8682

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 207Q00000X | Family Medicine Physician | 21324 | WV | Yes |

## Other

- **Enumeration date:** 08/07/2012
- **Last updated:** 08/18/2022