Healthcare Provider Details

I. General information

NPI: 1982833091
Provider Name (Legal Business Name): LANISE COOPER LACEY N.P.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/10/2009
Last Update Date: 10/11/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2500 N STATE ST
JACKSON MS
39216-4500
US

IV. Provider business mailing address

2500 N STATE ST
JACKSON MS
39216-4500
US

V. Phone/Fax

Practice location:
  • Phone: 601-925-6805
  • Fax: 601-926-4978
Mailing address:
  • Phone: 601-925-6805
  • Fax: 601-926-4978

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License NumberR864303
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: