Provider Demographics
NPI:1013643352
Name:LACY, KELLI BETH (PRSS)
Entity Type:Individual
Prefix:
First Name:KELLI
Middle Name:BETH
Last Name:LACY
Suffix:
Gender:F
Credentials:PRSS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:509 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:LOGAN
Mailing Address - State:WV
Mailing Address - Zip Code:25601-3809
Mailing Address - Country:US
Mailing Address - Phone:304-896-5008
Mailing Address - Fax:
Practice Address - Street 1:509 MAIN ST
Practice Address - Street 2:
Practice Address - City:LOGAN
Practice Address - State:WV
Practice Address - Zip Code:25601-3809
Practice Address - Country:US
Practice Address - Phone:304-896-5008
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-28
Last Update Date:2022-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV21-913175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist