Provider Demographics
NPI:1891772943
Name:NUNN, JENNIFER SUZANNE LACEY (MD)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:SUZANNE LACEY
Last Name:NUNN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:178 HOSPITAL RD STE A
Mailing Address - Street 2:
Mailing Address - City:BLAIRSVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30512-3139
Mailing Address - Country:US
Mailing Address - Phone:706-745-3671
Mailing Address - Fax:706-481-2700
Practice Address - Street 1:178 HOSPITAL RD STE A
Practice Address - Street 2:
Practice Address - City:BLAIRSVILLE
Practice Address - State:GA
Practice Address - Zip Code:30512-3139
Practice Address - Country:US
Practice Address - Phone:706-745-3671
Practice Address - Fax:706-481-2700
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-29
Last Update Date:2023-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA053008207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA89066J4Medicaid
GA187001OtherBLUE CROSS BLUE SHIELD
GA643758213AMedicaid
GA643758213AMedicaid
GA08BBQJDMedicare ID - Type UnspecifiedMEDICARE INDIVIDUAL
GAP00153442Medicare ID - Type UnspecifiedMEDICARE RAILROAD
GAH26909Medicare UPIN