Provider Demographics
NPI:1497486088
Name:HOLIFIELD, LACEDA
Entity Type:Individual
Prefix:MRS
First Name:LACEDA
Middle Name:
Last Name:HOLIFIELD
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 1:1708 22ND AVENUE HTS
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:MS
Mailing Address - Zip Code:39301-6809
Mailing Address - Country:US
Mailing Address - Phone:601-527-1581
Mailing Address - Fax:
Practice Address - Street 1:1708 22ND AVENUE HTS
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:MS
Practice Address - Zip Code:39301-6809
Practice Address - Country:US
Practice Address - Phone:601-527-1581
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-23
Last Update Date:2022-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver