Provider Demographics
NPI:1295207488
Name:HARVEY, LACEY MICHELLE (PA-C)
Entity Type:Individual
Prefix:
First Name:LACEY
Middle Name:MICHELLE
Last Name:HARVEY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:LACEY
Other - Middle Name:MICHELLE
Other - Last Name:LOPEZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 670
Mailing Address - Street 2:
Mailing Address - City:HUNTERTOWN
Mailing Address - State:IN
Mailing Address - Zip Code:46748-0670
Mailing Address - Country:US
Mailing Address - Phone:260-748-3650
Mailing Address - Fax:260-748-3651
Practice Address - Street 1:1721 MAGNAVOX WAY
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46804-1537
Practice Address - Country:US
Practice Address - Phone:260-748-3650
Practice Address - Fax:260-748-3651
Is Sole Proprietor?:No
Enumeration Date:2018-12-28
Last Update Date:2019-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN10002642A363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300021709Medicaid