Provider Demographics
NPI:1568011120
Name:TENN, LACANA N (MLT)
Entity Type:Individual
Prefix:MRS
First Name:LACANA
Middle Name:N
Last Name:TENN
Suffix:
Gender:F
Credentials:MLT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:569 KIMBERWICK DR
Mailing Address - Street 2:
Mailing Address - City:HAMPTON
Mailing Address - State:GA
Mailing Address - Zip Code:30228-3412
Mailing Address - Country:US
Mailing Address - Phone:678-521-6434
Mailing Address - Fax:
Practice Address - Street 1:106 NEW HOPE RD
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30214-1360
Practice Address - Country:US
Practice Address - Phone:678-521-6434
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-06
Last Update Date:2019-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAMT008312225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist