Provider Demographics
NPI:1760915524
Name:MARSHALL, LACEY
Entity Type:Individual
Prefix:MISS
First Name:LACEY
Middle Name:
Last Name:MARSHALL
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 1:1224 N TACOMA PL
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74127-5338
Mailing Address - Country:US
Mailing Address - Phone:918-804-7201
Mailing Address - Fax:
Practice Address - Street 1:1224 N TACOMA PL
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74127-5338
Practice Address - Country:US
Practice Address - Phone:918-804-7201
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-09
Last Update Date:2017-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK103510535171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator