Provider Demographics
NPI:1699390757
Name:CUSHMAN, LACY E (FNP-C)
Entity Type:Individual
Prefix:MRS
First Name:LACY
Middle Name:E
Last Name:CUSHMAN
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1622 MARY DUPRE DR
Mailing Address - Street 2:
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37421-2538
Mailing Address - Country:US
Mailing Address - Phone:423-432-7686
Mailing Address - Fax:
Practice Address - Street 1:1622 MARY DUPRE DR
Practice Address - Street 2:
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37421-2538
Practice Address - Country:US
Practice Address - Phone:423-432-7686
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-14
Last Update Date:2020-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN0000027377363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner