Provider Demographics
NPI:1437390416
Name:CAVANAUGH, LACEY MILLET (MD)
Entity Type:Individual
Prefix:
First Name:LACEY
Middle Name:MILLET
Last Name:CAVANAUGH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:LACEY
Other - Middle Name:ANN
Other - Last Name:MILLET
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:1905 COUNTRY CLUB RD
Mailing Address - Street 2:
Mailing Address - City:LAKE CHARLES
Mailing Address - State:LA
Mailing Address - Zip Code:70605-5203
Mailing Address - Country:US
Mailing Address - Phone:337-990-8000
Mailing Address - Fax:
Practice Address - Street 1:1905 COUNTRY CLUB RD
Practice Address - Street 2:
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70605-5203
Practice Address - Country:US
Practice Address - Phone:337-990-8000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-03-20
Last Update Date:2016-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
LAMD203896208D00000X
LAMD.203896207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice