Healthcare Provider Details

I. General information

NPI: 1992038574
Provider Name (Legal Business Name): LACEY GORHAM MCMANUS PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/14/2009
Last Update Date: 06/20/2024
Certification Date: 06/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

431 W LAFAYETTE ST
WINNFIELD LA
71483-3463
US

IV. Provider business mailing address

265 L SULLIVAN RD
WINNFIELD LA
71483-6451
US

V. Phone/Fax

Practice location:
  • Phone: 318-648-0375
  • Fax: 318-648-0378
Mailing address:
  • Phone: 318-209-9584
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA.200367
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: