Provider Demographics
NPI:1366965287
Name:THOMPSON, LACEY KATHLEEN (PA-C)
Entity type:Individual
Prefix:MRS
First Name:LACEY
Middle Name:KATHLEEN
Last Name:THOMPSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MRS
Other - First Name:LACEY
Other - Middle Name:
Other - Last Name:PROCTOR
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PA-S
Mailing Address - Street 1:127 CRESTVIEW PARK DR STE 209
Mailing Address - Street 2:
Mailing Address - City:DICKSON
Mailing Address - State:TN
Mailing Address - Zip Code:37055-2856
Mailing Address - Country:US
Mailing Address - Phone:615-441-4478
Mailing Address - Fax:615-446-1359
Practice Address - Street 1:125 CRESTVIEW PARK DR STE 2
Practice Address - Street 2:
Practice Address - City:DICKSON
Practice Address - State:TN
Practice Address - Zip Code:37055-2853
Practice Address - Country:US
Practice Address - Phone:615-446-1370
Practice Address - Fax:615-560-5998
Is Sole Proprietor?:No
Enumeration Date:2017-07-23
Last Update Date:2024-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
TN390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
ALPA-1566OtherAL LICENSE
TNPA3412OtherTN LICENSE