MEDICARE: MS. LACEY ANNE CONWAY FNP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	3014392	KY
2	363LF0000X	Family Nurse Practitioner	3014392	KY

General Provider Information

NPI Number	:	1184252777
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. LACEY ANNE CONWAY FNP

Provider Business Mailing Address
First Line	:	317 TYNE RD
Second Line	:
City	:	LOUISVILLE
State	:	KY
Zip	:	40207-3445
Country	:	US
Telephone Number	:	502-436-5989
Fax Number	:

Provider Business Practice Location Address
First Line	:	300 HIGH POINT CT
Second Line	:
City	:	MOUNT WASHINGTON
State	:	KY
Zip	:	40047-6560
Country	:	US
Telephone Number	:	502-955-6129
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/30/2020
Last Update Date	:	03/22/2022

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