Provider Demographics
NPI:1780405373
Name:LACY, ALICIA CAMILLE
Entity type:Individual
Prefix:
First Name:ALICIA
Middle Name:CAMILLE
Last Name:LACY
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 1:2227 W MARKET ST FL 2
Mailing Address - Street 2:
Mailing Address - City:YORK
Mailing Address - State:PA
Mailing Address - Zip Code:17404-5516
Mailing Address - Country:US
Mailing Address - Phone:717-318-1904
Mailing Address - Fax:888-527-3213
Practice Address - Street 1:2227 W MARKET ST FL 2
Practice Address - Street 2:
Practice Address - City:YORK
Practice Address - State:PA
Practice Address - Zip Code:17404-5516
Practice Address - Country:US
Practice Address - Phone:717-318-1904
Practice Address - Fax:888-527-3213
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-17
Last Update Date:2024-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA29012447172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver