Provider Demographics
NPI:1023577822
Name:LACY-BARKER, DESMOND DE'VON
Entity Type:Individual
Prefix:
First Name:DESMOND
Middle Name:DE'VON
Last Name:LACY-BARKER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1102 WALTON AVE
Mailing Address - Street 2:
Mailing Address - City:RACINE
Mailing Address - State:WI
Mailing Address - Zip Code:53402-4549
Mailing Address - Country:US
Mailing Address - Phone:262-598-7590
Mailing Address - Fax:
Practice Address - Street 1:1102 WALTON AVE
Practice Address - Street 2:
Practice Address - City:RACINE
Practice Address - State:WI
Practice Address - Zip Code:53402-4549
Practice Address - Country:US
Practice Address - Phone:262-598-7590
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-19
Last Update Date:2019-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver