Healthcare Provider Details

I. General information

NPI: 1710677638
Provider Name (Legal Business Name): LACY LISBON LM, CPM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/12/2023
Last Update Date: 01/19/2025
Certification Date: 01/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2658 E ALLUVIAL AVE APT 118
FRESNO CA
93720-9111
US

IV. Provider business mailing address

2658 E ALLUVIAL AVE APT 118
FRESNO CA
93720-9111
US

V. Phone/Fax

Practice location:
  • Phone: 559-905-5933
  • Fax:
Mailing address:
  • Phone: 559-905-5933
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code176B00000X
TaxonomyMidwife
License Number708
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code374J00000X
TaxonomyDoula
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: