Provider Demographics
NPI:1114405354
Name:GUDGER, LACIE GAIL (NP-C)
Entity Type:Individual
Prefix:
First Name:LACIE
Middle Name:GAIL
Last Name:GUDGER
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:LACIE
Other - Middle Name:GAIL
Other - Last Name:THOMPSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6350 W ANDREW JOHNSON HWY
Mailing Address - Street 2:
Mailing Address - City:TALBOTT
Mailing Address - State:TN
Mailing Address - Zip Code:37877-8605
Mailing Address - Country:US
Mailing Address - Phone:800-355-3565
Mailing Address - Fax:423-714-2355
Practice Address - Street 1:3360 HIGHWAY 411 N
Practice Address - Street 2:
Practice Address - City:ENGLEWOOD
Practice Address - State:TN
Practice Address - Zip Code:37329-5276
Practice Address - Country:US
Practice Address - Phone:423-887-5131
Practice Address - Fax:423-887-5917
Is Sole Proprietor?:No
Enumeration Date:2018-07-31
Last Update Date:2020-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNRN181114163W00000X
TNAPN24561363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse