Provider Demographics
NPI:1194504936
Name:DUFF, LACEY AMANDA (PTA)
Entity type:Individual
Prefix:
First Name:LACEY
Middle Name:AMANDA
Last Name:DUFF
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3115 WILLOW WISP WAY
Mailing Address - Street 2:
Mailing Address - City:CUMMING
Mailing Address - State:GA
Mailing Address - Zip Code:30040-7185
Mailing Address - Country:US
Mailing Address - Phone:937-567-2834
Mailing Address - Fax:
Practice Address - Street 1:815 ATLANTA HWY
Practice Address - Street 2:
Practice Address - City:CUMMING
Practice Address - State:GA
Practice Address - Zip Code:30040-2707
Practice Address - Country:US
Practice Address - Phone:770-888-4929
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-21
Last Update Date:2023-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA003732225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant