Healthcare Provider Details

I. General information

NPI: 1003725458
Provider Name (Legal Business Name): MORGAN LACEY SANTIAGO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MORGAN LACEY MCCOY

II. Dates (important events)

Enumeration Date: 09/02/2026
Last Update Date: 09/02/2026
Certification Date: 09/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

370 TANYARD RD
ROCKY MOUNT VA
24151-1554
US

IV. Provider business mailing address

370 TANYARD RD
ROCKY MOUNT VA
24151-1554
US

V. Phone/Fax

Practice location:
  • Phone: 540-488-5636
  • Fax: 888-808-3395
Mailing address:
  • Phone: 540-488-5636
  • Fax: 888-808-3395

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number0734015334
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: