Provider Demographics
NPI:1205356565
Name:CONRY, LACY JOHNSON (PA)
Entity Type:Individual
Prefix:MS
First Name:LACY
Middle Name:JOHNSON
Last Name:CONRY
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6077 PRIMACY PKWY STE 140
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38119-5742
Mailing Address - Country:US
Mailing Address - Phone:901-725-8347
Mailing Address - Fax:901-259-7637
Practice Address - Street 1:3045 KATE BOND RD
Practice Address - Street 2:
Practice Address - City:BARTLETT
Practice Address - State:TN
Practice Address - Zip Code:38133-4004
Practice Address - Country:US
Practice Address - Phone:901-641-3000
Practice Address - Fax:901-373-3804
Is Sole Proprietor?:No
Enumeration Date:2017-06-27
Last Update Date:2021-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN3316363AM0700X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1136210OtherNCCPA
TN3316OtherLICENSE UPDATE