Provider Demographics
NPI:1851521819
Name:CRISSUP, LACY NICOLE (OD)
Entity Type:Individual
Prefix:DR
First Name:LACY
Middle Name:NICOLE
Last Name:CRISSUP
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:LACY
Other - Middle Name:NICOLE
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:212 E BLUE STARR DR
Mailing Address - Street 2:
Mailing Address - City:CLAREMORE
Mailing Address - State:OK
Mailing Address - Zip Code:74017-4223
Mailing Address - Country:US
Mailing Address - Phone:918-341-8211
Mailing Address - Fax:918-341-8233
Practice Address - Street 1:212 E BLUE STARR DR
Practice Address - Street 2:
Practice Address - City:CLAREMORE
Practice Address - State:OK
Practice Address - Zip Code:74017-4223
Practice Address - Country:US
Practice Address - Phone:918-341-8211
Practice Address - Fax:918-341-8233
Is Sole Proprietor?:No
Enumeration Date:2009-07-23
Last Update Date:2009-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2600152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist