Provider Demographics
NPI:1154093821
Name:SANSBURN, LACY ELIZABETH (PT)
Entity Type:Individual
Prefix:DR
First Name:LACY
Middle Name:ELIZABETH
Last Name:SANSBURN
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 9118
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55480-9118
Mailing Address - Country:US
Mailing Address - Phone:615-329-2294
Mailing Address - Fax:615-695-1494
Practice Address - Street 1:141 HILLCREST DR
Practice Address - Street 2:
Practice Address - City:CLARKSVILLE
Practice Address - State:TN
Practice Address - Zip Code:37043-5088
Practice Address - Country:US
Practice Address - Phone:931-552-4340
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-01
Last Update Date:2022-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN139082251X0800X
KY0079532251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ070228Medicaid