Provider Demographics
NPI:1811322522
Name:WALK, LACEY LEANN (OD)
Entity type:Individual
Prefix:
First Name:LACEY
Middle Name:LEANN
Last Name:WALK
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:LACEY
Other - Middle Name:
Other - Last Name:FEEZEL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:15933 CLAYTON RD
Mailing Address - Street 2:SUITE 201
Mailing Address - City:BALLWIN
Mailing Address - State:MO
Mailing Address - Zip Code:63011-2172
Mailing Address - Country:US
Mailing Address - Phone:636-200-4393
Mailing Address - Fax:636-527-0766
Practice Address - Street 1:10 LINCOLN HWY STE 101
Practice Address - Street 2:
Practice Address - City:FAIRVIEW HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:62208-2100
Practice Address - Country:US
Practice Address - Phone:618-624-0222
Practice Address - Fax:618-624-4930
Is Sole Proprietor?:No
Enumeration Date:2013-09-12
Last Update Date:2017-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0406010739152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILF400204148Medicare PIN