Provider Demographics
NPI:1922510635
Name:LAKE FOREMAN, LACEY DARLENE (CRNP)
Entity Type:Individual
Prefix:
First Name:LACEY
Middle Name:DARLENE
Last Name:LAKE FOREMAN
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:LACEY
Other - Middle Name:DARLENE
Other - Last Name:LAKE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:117 EDINBORO DR
Mailing Address - Street 2:
Mailing Address - City:GREENSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:15601
Mailing Address - Country:US
Mailing Address - Phone:724-875-7632
Mailing Address - Fax:
Practice Address - Street 1:3520 ROUTE 130 BLDG 3
Practice Address - Street 2:
Practice Address - City:IRWIN
Practice Address - State:PA
Practice Address - Zip Code:15642-1438
Practice Address - Country:US
Practice Address - Phone:724-744-1408
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-11-03
Last Update Date:2017-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP018060363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner