Provider Demographics
NPI:1336490713
Name:BRACKEEN, LACIE A (CFNP)
Entity Type:Individual
Prefix:
First Name:LACIE
Middle Name:A
Last Name:BRACKEEN
Suffix:
Gender:F
Credentials:CFNP
Other - Prefix:
Other - First Name:LACIE
Other - Middle Name:F
Other - Last Name:ARRINGTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CFNP
Mailing Address - Street 1:201 BAKER BLVD
Mailing Address - Street 2:
Mailing Address - City:LELAND
Mailing Address - State:MS
Mailing Address - Zip Code:38756-3401
Mailing Address - Country:US
Mailing Address - Phone:662-686-4121
Mailing Address - Fax:662-686-4770
Practice Address - Street 1:201 BAKER BLVD
Practice Address - Street 2:
Practice Address - City:LELAND
Practice Address - State:MS
Practice Address - Zip Code:38756-3401
Practice Address - Country:US
Practice Address - Phone:662-686-4121
Practice Address - Fax:662-686-4770
Is Sole Proprietor?:No
Enumeration Date:2012-09-26
Last Update Date:2019-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR858018363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS06425036Medicaid