Provider Demographics
NPI:1902497597
Name:CRIMMINS, LACCEY LOUISE (ARNP)
Entity Type:Individual
Prefix:MRS
First Name:LACCEY
Middle Name:LOUISE
Last Name:CRIMMINS
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:LACCEY
Other - Middle Name:LOUISE
Other - Last Name:LISKA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2476 170TH ST
Mailing Address - Street 2:
Mailing Address - City:FORT DODGE
Mailing Address - State:IA
Mailing Address - Zip Code:50501-8555
Mailing Address - Country:US
Mailing Address - Phone:515-408-5155
Mailing Address - Fax:515-574-6754
Practice Address - Street 1:802 KENYON RD
Practice Address - Street 2:
Practice Address - City:FORT DODGE
Practice Address - State:IA
Practice Address - Zip Code:50501-5740
Practice Address - Country:US
Practice Address - Phone:515-573-3101
Practice Address - Fax:515-574-6754
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-27
Last Update Date:2022-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAA162720363LF0000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IAF01210805Medicaid