Provider Demographics
NPI:1447005822
Name:CARROLL, LACY JEAN
Entity type:Individual
Prefix:
First Name:LACY
Middle Name:JEAN
Last Name:CARROLL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:356110 E 930 RD
Mailing Address - Street 2:
Mailing Address - City:STROUD
Mailing Address - State:OK
Mailing Address - Zip Code:74079-5184
Mailing Address - Country:US
Mailing Address - Phone:918-968-3531
Mailing Address - Fax:
Practice Address - Street 1:356110 E 930 RD
Practice Address - Street 2:
Practice Address - City:STROUD
Practice Address - State:OK
Practice Address - Zip Code:74079-5184
Practice Address - Country:US
Practice Address - Phone:918-968-3531
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-19
Last Update Date:2024-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist