Provider Demographics
NPI:1649002064
Name:LACY, TINIYA BRANDY (NP)
Entity type:Individual
Prefix:MS
First Name:TINIYA
Middle Name:BRANDY
Last Name:LACY
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11797 FOREST PARK LN
Mailing Address - Street 2:
Mailing Address - City:VICTORVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:92392-0428
Mailing Address - Country:US
Mailing Address - Phone:760-662-9940
Mailing Address - Fax:
Practice Address - Street 1:18522 US HIGHWAY 18 STE 102
Practice Address - Street 2:
Practice Address - City:APPLE VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92307-2321
Practice Address - Country:US
Practice Address - Phone:760-242-7707
Practice Address - Fax:760-242-1133
Is Sole Proprietor?:No
Enumeration Date:2024-08-14
Last Update Date:2024-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95046480163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse