Provider Demographics
NPI:1720375298
Name:LEE, LACEY WHITAKER (RN)
Entity Type:Individual
Prefix:
First Name:LACEY
Middle Name:WHITAKER
Last Name:LEE
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 918
Mailing Address - Street 2:
Mailing Address - City:BENNETTSVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29512
Mailing Address - Country:US
Mailing Address - Phone:843-454-0442
Mailing Address - Fax:843-454-0212
Practice Address - Street 1:1035 CHERAW ST.
Practice Address - Street 2:
Practice Address - City:BENNETTSVILLE
Practice Address - State:SC
Practice Address - Zip Code:29512
Practice Address - Country:US
Practice Address - Phone:843-454-0442
Practice Address - Fax:843-454-0212
Is Sole Proprietor?:No
Enumeration Date:2011-07-06
Last Update Date:2011-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC210650163WP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC405127Medicaid
SC405127Medicaid