Healthcare Provider Details

I. General information

NPI: 1881017655
Provider Name (Legal Business Name): LACEY TUDOR PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LACEY LUMPKIN

II. Dates (important events)

Enumeration Date: 01/29/2014
Last Update Date: 01/29/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8260 ATLEE RD EMERGENCY DEPT.
MECHANICSVILLE VA
23116-1844
US

IV. Provider business mailing address

38935 ANN ARBOR RD CREDENTIALING DEPT
LIVONIA MI
48150-3397
US

V. Phone/Fax

Practice location:
  • Phone: 804-764-6300
  • Fax: 804-764-6562
Mailing address:
  • Phone: 734-805-0488
  • Fax: 866-250-6385

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0110004486
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: