Provider Demographics
NPI:1174127781
Name:CRUM, LACY MARIE
Entity type:Individual
Prefix:
First Name:LACY
Middle Name:MARIE
Last Name:CRUM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:LACY
Other - Middle Name:MARIE
Other - Last Name:CRUM
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PA-C
Mailing Address - Street 1:PO BOX 936
Mailing Address - Street 2:
Mailing Address - City:LONDON
Mailing Address - State:KY
Mailing Address - Zip Code:40743-0936
Mailing Address - Country:US
Mailing Address - Phone:859-497-5160
Mailing Address - Fax:
Practice Address - Street 1:227 FALCON DR # 104
Practice Address - Street 2:
Practice Address - City:MT STERLING
Practice Address - State:KY
Practice Address - Zip Code:40353-9792
Practice Address - Country:US
Practice Address - Phone:859-497-5160
Practice Address - Fax:859-497-5166
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-24
Last Update Date:2022-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYPA2799363AM0700X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100771230Medicaid