Healthcare Provider Details

I. General information

NPI: 1366965287
Provider Name (Legal Business Name): LACEY KATHLEEN THOMPSON PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LACEY PROCTOR PA-S

II. Dates (important events)

Enumeration Date: 07/23/2017
Last Update Date: 10/28/2024
Certification Date: 10/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

125 CRESTVIEW PARK DR STE 2
DICKSON TN
37055-2853
US

IV. Provider business mailing address

127 CRESTVIEW PARK DR STE 209
DICKSON TN
37055-2856
US

V. Phone/Fax

Practice location:
  • Phone: 615-446-1370
  • Fax: 615-560-5998
Mailing address:
  • Phone: 615-441-4478
  • Fax: 615-446-1359

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: