Healthcare Provider Details

I. General information

NPI: 1962250282
Provider Name (Legal Business Name): LYJIRIA LACY PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/10/2024
Last Update Date: 07/10/2026
Certification Date: 07/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2075 HAMILTON CREEK PKWY UNIT 200
DACULA GA
30019-7285
US

IV. Provider business mailing address

2075 HAMILTON CREEK PKWY UNIT 200
DACULA GA
30019-7285
US

V. Phone/Fax

Practice location:
  • Phone: 770-586-0300
  • Fax: 770-586-0300
Mailing address:
  • Phone: 770-586-0300
  • Fax: 770-586-0300

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number13673
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code207RS0012X
TaxonomySleep Medicine (Internal Medicine) Physician
License Number13673
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: