Provider Demographics
NPI:1437306321
Name:CRABB, LACEY L (FNP)
Entity type:Individual
Prefix:
First Name:LACEY
Middle Name:L
Last Name:CRABB
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1414 W FAIR AVE
Mailing Address - Street 2:SUITE 342
Mailing Address - City:MARQUETTE
Mailing Address - State:MI
Mailing Address - Zip Code:49855-2675
Mailing Address - Country:US
Mailing Address - Phone:906-225-3870
Mailing Address - Fax:906-225-3975
Practice Address - Street 1:1414 W FAIR AVE
Practice Address - Street 2:SUITE 342
Practice Address - City:MARQUETTE
Practice Address - State:MI
Practice Address - Zip Code:49855-2675
Practice Address - Country:US
Practice Address - Phone:906-225-3870
Practice Address - Fax:906-225-3975
Is Sole Proprietor?:No
Enumeration Date:2008-08-21
Last Update Date:2009-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704244170363L00000X, 207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5008707680OtherBLUE CROSS BLUE SHIELD
MI0870768OtherBCBS OF MI
MI1437306321Medicaid
MI0870768OtherBCBS OF MI
MIP17990008Medicare PIN