Provider Demographics
NPI:1366670382
Name:KRUSE, LACEY (MD)
Entity Type:Individual
Prefix:
First Name:LACEY
Middle Name:
Last Name:KRUSE
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:PO BOX 19656
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62794-9656
Mailing Address - Country:US
Mailing Address - Phone:217-545-8853
Mailing Address - Fax:217-545-0828
Practice Address - Street 1:751 N RUTLEDGE ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62702-4909
Practice Address - Country:US
Practice Address - Phone:217-545-3821
Practice Address - Fax:217-545-7438
Is Sole Proprietor?:No
Enumeration Date:2009-06-29
Last Update Date:2013-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125-055766207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology