Healthcare Provider Details

I. General information

NPI: 1326457151
Provider Name (Legal Business Name): LACEY BLAKENEY NP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/06/2014
Last Update Date: 04/01/2024
Certification Date: 03/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1002 JEFFERSON STREET SUITE 450
LAUREL MS
39440-4327
US

IV. Provider business mailing address

39 FRANKLIN RD STE 300
HATTIESBURG MS
39402-1588
US

V. Phone/Fax

Practice location:
  • Phone: 601-428-0438
  • Fax:
Mailing address:
  • Phone: 601-268-9393
  • Fax: 601-268-9559

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR872620
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: