Provider Demographics
NPI:1598007106
Name:CRAWFORD, LACIE WHITTEN (PA-C)
Entity type:Individual
Prefix:MRS
First Name:LACIE
Middle Name:WHITTEN
Last Name:CRAWFORD
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MISS
Other - First Name:LACIE
Other - Middle Name:ANNA
Other - Last Name:WHITTEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:1211 UNION AVE STE 330
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38104-6655
Mailing Address - Country:US
Mailing Address - Phone:901-516-0881
Mailing Address - Fax:901-516-0954
Practice Address - Street 1:7460 WOLF RIVER BLVD
Practice Address - Street 2:
Practice Address - City:GERMANTOWN
Practice Address - State:TN
Practice Address - Zip Code:38138
Practice Address - Country:US
Practice Address - Phone:901-763-0200
Practice Address - Fax:901-761-4002
Is Sole Proprietor?:No
Enumeration Date:2013-03-21
Last Update Date:2018-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL889363AM0700X
TN2331363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical