Healthcare Provider Details

I. General information

NPI: 1649161480
Provider Name (Legal Business Name): LACEY HESTER CHILDREE NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/10/2025
Last Update Date: 09/23/2025
Certification Date: 09/23/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

39 KENT RD STE 2
TIFTON GA
31794-1697
US

IV. Provider business mailing address

47 LOGANBERRY CIR
VALDOSTA GA
31602-2303
US

V. Phone/Fax

Practice location:
  • Phone: 229-353-4368
  • Fax:
Mailing address:
  • Phone: 229-237-8709
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN-NP291799
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: