Provider Demographics
NPI:1497149454
Name:LOCKHART, LACEY BETH
Entity Type:Individual
Prefix:
First Name:LACEY BETH
Middle Name:
Last Name:LOCKHART
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 1:9115 SW OLESON RD STE 205
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97223-6877
Mailing Address - Country:US
Mailing Address - Phone:503-245-2420
Mailing Address - Fax:
Practice Address - Street 1:12400 NW CORNELL RD STE 201
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97229-5689
Practice Address - Country:US
Practice Address - Phone:503-643-1737
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-03-26
Last Update Date:2022-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORDP192989213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery