Healthcare Provider Details

I. General information

NPI: 1902497597
Provider Name (Legal Business Name): LACCEY LOUISE CRIMMINS ARNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: LACCEY LOUISE LISKA

II. Dates (important events)

Enumeration Date: 01/27/2021
Last Update Date: 03/04/2022
Certification Date: 03/04/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

802 KENYON RD
FORT DODGE IA
50501-5740
US

IV. Provider business mailing address

2476 170TH ST
FORT DODGE IA
50501-8555
US

V. Phone/Fax

Practice location:
  • Phone: 515-573-3101
  • Fax: 515-574-6754
Mailing address:
  • Phone: 515-408-5155
  • Fax: 515-574-6754

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberA162720
License Number StateIA
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberA162720
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: