Provider Demographics
NPI:1508950841
Name:LACEY, JOANNE L (MD)
Entity Type:Individual
Prefix:DR
First Name:JOANNE
Middle Name:L
Last Name:LACEY
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 1:108 FRONTENAC FRST
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63131-3218
Mailing Address - Country:US
Mailing Address - Phone:314-497-2368
Mailing Address - Fax:
Practice Address - Street 1:108 FRONTENAC FRST
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63131-3218
Practice Address - Country:US
Practice Address - Phone:314-497-2368
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2022-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20040016462085N0700X, 2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085N0700XAllopathic & Osteopathic PhysiciansRadiologyNeuroradiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO209014307Medicaid
MO107690004Medicare PIN
MO209014307Medicaid
121022Medicare UPIN