Provider Demographics
NPI:1083984223
Name:DENNIS, LACEY NICOLE (RN)
Entity Type:Individual
Prefix:
First Name:LACEY
Middle Name:NICOLE
Last Name:DENNIS
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 157
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:TN
Mailing Address - Zip Code:37322-0157
Mailing Address - Country:US
Mailing Address - Phone:423-334-5185
Mailing Address - Fax:
Practice Address - Street 1:389 RIVER RD
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:TN
Practice Address - Zip Code:37322-7801
Practice Address - Country:US
Practice Address - Phone:423-334-5185
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-05
Last Update Date:2012-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN177513163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse