Provider Demographics
NPI:1043624083
Name:LAKE, LACEY JO
Entity type:Individual
Prefix:
First Name:LACEY
Middle Name:JO
Last Name:LAKE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:LACEY
Other - Middle Name:JO
Other - Last Name:MCFADDEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2114 PINEFIELD ST
Mailing Address - Street 2:
Mailing Address - City:MUSCATINE
Mailing Address - State:IA
Mailing Address - Zip Code:52761-2553
Mailing Address - Country:US
Mailing Address - Phone:563-607-2372
Mailing Address - Fax:
Practice Address - Street 1:2114 PINEFIELD ST
Practice Address - Street 2:
Practice Address - City:MUSCATINE
Practice Address - State:IA
Practice Address - Zip Code:52761-2553
Practice Address - Country:US
Practice Address - Phone:563-607-2372
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-18
Last Update Date:2014-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA11471247100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247100000XTechnologists, Technicians & Other Technical Service ProvidersRadiologic Technologist