Healthcare Provider Details

I. General information

NPI: 1003076142
Provider Name (Legal Business Name): SHANON RENEE LACY D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/12/2008
Last Update Date: 12/30/2021
Certification Date: 12/30/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8901 W LINCOLN AVE
WEST ALLIS WI
53227-2409
US

IV. Provider business mailing address

102 N WATER ST UNIT 206
MILWAUKEE WI
53202-6056
US

V. Phone/Fax

Practice location:
  • Phone: 414-328-7675
  • Fax:
Mailing address:
  • Phone: 317-285-9918
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207ZD0900X
TaxonomyDermatopathology (Pathology) Physician
License Number56999-21
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number56999-21
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: