Provider Demographics
NPI:1750646279
Name:BURKES, LACY D (PNP)
Entity Type:Individual
Prefix:
First Name:LACY
Middle Name:D
Last Name:BURKES
Suffix:
Gender:F
Credentials:PNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:4922 SPRING AVENUE
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75210-1359
Mailing Address - Country:US
Mailing Address - Phone:469-488-4700
Mailing Address - Fax:469-488-4701
Practice Address - Street 1:205 W TYLER ST
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:TX
Practice Address - Zip Code:75103-1352
Practice Address - Country:US
Practice Address - Phone:903-567-5437
Practice Address - Fax:844-678-6258
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-10
Last Update Date:2020-01-28
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TX754047363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics