Provider Demographics
NPI:1043403751
Name:LACY, KIMBERLY KAY (DO)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:KAY
Last Name:LACY
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:306 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:RURAL RETREAT
Mailing Address - State:VA
Mailing Address - Zip Code:24368-3269
Mailing Address - Country:US
Mailing Address - Phone:276-686-4007
Mailing Address - Fax:
Practice Address - Street 1:306 S MAIN ST
Practice Address - Street 2:
Practice Address - City:RURAL RETREAT
Practice Address - State:VA
Practice Address - Zip Code:24368-3269
Practice Address - Country:US
Practice Address - Phone:276-686-4007
Practice Address - Fax:276-686-4581
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-26
Last Update Date:2024-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0102202349207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1043403751Medicaid