Healthcare Provider Details

I. General information

NPI: 1184536310
Provider Name (Legal Business Name): LACIE YARBROUGH CST
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/22/2026
Last Update Date: 09/22/2026
Certification Date: 09/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1432 KIMBROUGH RD
GERMANTOWN TN
38138-2405
US

IV. Provider business mailing address

81 BLOOMINGTON DR
BRIGHTON TN
38011-4092
US

V. Phone/Fax

Practice location:
  • Phone: 901-571-3909
  • Fax:
Mailing address:
  • Phone: 901-571-3909
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246ZS0410X
TaxonomySurgical Technologist
License Number100283126
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: