Healthcare Provider Details

I. General information

NPI: 1033923909
Provider Name (Legal Business Name): MARNA LACY-BARKER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/03/2025
Last Update Date: 02/03/2025
Certification Date: 02/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

31581 GRATIOT AVE
ROSEVILLE MI
48066-4528
US

IV. Provider business mailing address

31581 GRATIOT AVE
ROSEVILLE MI
48066-4528
US

V. Phone/Fax

Practice location:
  • Phone: 586-783-4802
  • Fax:
Mailing address:
  • Phone: 586-783-4802
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number23348051501
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: