Provider Demographics
NPI:1427533306
Name:LUCAS, KATINA LACHELLA
Entity type:Individual
Prefix:
First Name:KATINA
Middle Name:LACHELLA
Last Name:LUCAS
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 1:2837 MOORE RD
Mailing Address - Street 2:
Mailing Address - City:RED BANKS
Mailing Address - State:MS
Mailing Address - Zip Code:38661-9652
Mailing Address - Country:US
Mailing Address - Phone:901-827-5581
Mailing Address - Fax:
Practice Address - Street 1:2837 MOORE RD
Practice Address - Street 2:
Practice Address - City:RED BANKS
Practice Address - State:MS
Practice Address - Zip Code:38661-9652
Practice Address - Country:US
Practice Address - Phone:901-827-5581
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-26
Last Update Date:2018-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS801684845172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver