Healthcare Provider Details

I. General information

NPI: 1083540900
Provider Name (Legal Business Name): LACY BLACKMON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/18/2026
Last Update Date: 06/18/2026
Certification Date: 06/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1751 JACKSON ST
ALEXANDRIA LA
71301-6433
US

IV. Provider business mailing address

1751 JACKSON ST
ALEXANDRIA LA
71301-6433
US

V. Phone/Fax

Practice location:
  • Phone: 318-445-5678
  • Fax:
Mailing address:
  • Phone: 318-445-5678
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: