Provider Demographics
NPI:1629425715
Name:RODDY, LACIE L (FNP-BC RM)
Entity Type:Individual
Prefix:
First Name:LACIE
Middle Name:L
Last Name:RODDY
Suffix:
Gender:F
Credentials:FNP-BC RM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1300 CLEVELAND AVE
Mailing Address - Street 2:
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37404-2005
Mailing Address - Country:US
Mailing Address - Phone:423-756-7860
Mailing Address - Fax:423-756-9137
Practice Address - Street 1:1300 CLEVELAND AVE
Practice Address - Street 2:
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37404-2005
Practice Address - Country:US
Practice Address - Phone:423-756-7860
Practice Address - Fax:423-756-9137
Is Sole Proprietor?:No
Enumeration Date:2016-05-18
Last Update Date:2019-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNAPN20829163WU0100X
TN20829363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163WU0100XNursing Service ProvidersRegistered NurseUrology