Provider Demographics
NPI:1205392248
Name:LACEY, YOLANDA QUANTA
Entity Type:Individual
Prefix:
First Name:YOLANDA
Middle Name:QUANTA
Last Name:LACEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:34 LACEY RD
Mailing Address - Street 2:
Mailing Address - City:BUCKATUNNA
Mailing Address - State:MS
Mailing Address - Zip Code:39322-9707
Mailing Address - Country:US
Mailing Address - Phone:601-410-1141
Mailing Address - Fax:
Practice Address - Street 1:34 LACEY RD
Practice Address - Street 2:
Practice Address - City:BUCKATUNNA
Practice Address - State:MS
Practice Address - Zip Code:39322-9707
Practice Address - Country:US
Practice Address - Phone:601-410-0950
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-14
Last Update Date:2019-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS800659693343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)