Provider Demographics
NPI:1124223649
Name:GREGORY, LACIE (MD)
Entity Type:Individual
Prefix:
First Name:LACIE
Middle Name:
Last Name:GREGORY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:507 E 16TH ST STE 1
Mailing Address - Street 2:
Mailing Address - City:WELLINGTON
Mailing Address - State:KS
Mailing Address - Zip Code:67152-2828
Mailing Address - Country:US
Mailing Address - Phone:620-326-3301
Mailing Address - Fax:
Practice Address - Street 1:507 E 16TH ST STE 1
Practice Address - Street 2:
Practice Address - City:WELLINGTON
Practice Address - State:KS
Practice Address - Zip Code:67152-2828
Practice Address - Country:US
Practice Address - Phone:620-326-3301
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-15
Last Update Date:2020-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS046718207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS1124223649Medicaid
1255500633OtherNON RHC NPI
12132729OtherCAQH
KS04-33377OtherKANSAS LICENSE
1124223649OtherBCBS OF KANSAS
1437283991OtherBCBS GROUP NPI
1255500633OtherNON RHC NPI