Provider Demographics
NPI:1821521345
Name:FISK, LACEY
Entity Type:Individual
Prefix:
First Name:LACEY
Middle Name:
Last Name:FISK
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 1:1118 2ND AVE
Mailing Address - Street 2:
Mailing Address - City:FAIRBANKS
Mailing Address - State:AK
Mailing Address - Zip Code:99701-4228
Mailing Address - Country:US
Mailing Address - Phone:907-456-6213
Mailing Address - Fax:907-452-5925
Practice Address - Street 1:1118 2ND AVE
Practice Address - Street 2:
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99701-4228
Practice Address - Country:US
Practice Address - Phone:907-456-6213
Practice Address - Fax:907-452-5925
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-11
Last Update Date:2017-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK120919174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist