Provider Demographics
NPI:1831667104
Name:VINCENT, LACY CULVER (PA)
Entity Type:Individual
Prefix:
First Name:LACY
Middle Name:CULVER
Last Name:VINCENT
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4396 HIGHWAY 80
Mailing Address - Street 2:
Mailing Address - City:RUSTON
Mailing Address - State:LA
Mailing Address - Zip Code:71270-8948
Mailing Address - Country:US
Mailing Address - Phone:318-251-4659
Mailing Address - Fax:318-513-3612
Practice Address - Street 1:4396 HIGHWAY 80
Practice Address - Street 2:
Practice Address - City:RUSTON
Practice Address - State:LA
Practice Address - Zip Code:71270-8948
Practice Address - Country:US
Practice Address - Phone:318-550-8928
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-05
Last Update Date:2020-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA310464363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant