Provider Demographics
NPI:1306359641
Name:WORTHAM, LACIE
Entity Type:Individual
Prefix:
First Name:LACIE
Middle Name:
Last Name:WORTHAM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4050 LAKE OTIS PKWY STE 107
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99508-5220
Mailing Address - Country:US
Mailing Address - Phone:907-252-8958
Mailing Address - Fax:
Practice Address - Street 1:4050 LAKE OTIS PKWY STE 107
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99508-5220
Practice Address - Country:US
Practice Address - Phone:907-252-8958
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-11-08
Last Update Date:2020-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK101628111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK46-5425549OtherMANUAL THERAPIST