Healthcare Provider Details

I. General information

NPI: 1740022474
Provider Name (Legal Business Name): LACEY GENTRY CNM291392
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/12/2024
Last Update Date: 07/23/2026
Certification Date: 07/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 JOHNSON FERRY RD
SANDY SPRINGS GA
30342-1606
US

IV. Provider business mailing address

5112 ACWORTH LANDING DR
ACWORTH GA
30101-5347
US

V. Phone/Fax

Practice location:
  • Phone: 404-851-1000
  • Fax:
Mailing address:
  • Phone: 678-389-0166
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367A00000X
TaxonomyAdvanced Practice Midwife
License NumberRN291392
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: