Provider Demographics
NPI:1710998729
Name:LACY, SUSAN NORTHERN (MD)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:NORTHERN
Last Name:LACY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1407 UNION AVE
Mailing Address - Street 2:STE 1401
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38104-3667
Mailing Address - Country:US
Mailing Address - Phone:901-701-1777
Mailing Address - Fax:901-701-1778
Practice Address - Street 1:6401 POPLAR AVE STE 530
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38119-4840
Practice Address - Country:US
Practice Address - Phone:901-767-9368
Practice Address - Fax:901-767-9496
Is Sole Proprietor?:No
Enumeration Date:2006-08-11
Last Update Date:2019-11-01
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
TN28143207VX0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VX0000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyObstetrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNG62902Medicare UPIN