Provider Demographics
NPI:1861832404
Name:JOHNSON, LACEY A (APRN)
Entity type:Individual
Prefix:
First Name:LACEY
Middle Name:A
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:480 HOPKINSVILLE ST
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:42345-1124
Mailing Address - Country:US
Mailing Address - Phone:270-338-5777
Mailing Address - Fax:270-338-5765
Practice Address - Street 1:228 HOPKINSVILLE ST
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:KY
Practice Address - Zip Code:42345-1214
Practice Address - Country:US
Practice Address - Phone:270-377-3077
Practice Address - Fax:270-377-3002
Is Sole Proprietor?:No
Enumeration Date:2013-06-27
Last Update Date:2025-02-11
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
KY3008081363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100249540Medicaid
KY7100249540Medicaid