Provider Demographics
NPI:1962707745
Name:SULLIVAN, LACEY (MD)
Entity type:Individual
Prefix:
First Name:LACEY
Middle Name:
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5052 W 4TH ST STE 7
Mailing Address - Street 2:
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39402-1069
Mailing Address - Country:US
Mailing Address - Phone:601-261-2587
Mailing Address - Fax:601-264-7426
Practice Address - Street 1:2809 DENNY AVE
Practice Address - Street 2:
Practice Address - City:PASCAGOULA
Practice Address - State:MS
Practice Address - Zip Code:39581
Practice Address - Country:US
Practice Address - Phone:228-818-6063
Practice Address - Fax:228-809-2254
Is Sole Proprietor?:No
Enumeration Date:2011-01-25
Last Update Date:2019-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALMD.35922207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology