Provider Demographics
NPI:1972043305
Name:BURGE, LACIE SHAE
Entity Type:Individual
Prefix:MRS
First Name:LACIE
Middle Name:SHAE
Last Name:BURGE
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 1:1100 REID PARKWAY
Mailing Address - Street 2:MEDICAL STAFF SERVICES
Mailing Address - City:RICHMOND
Mailing Address - State:IN
Mailing Address - Zip Code:47374
Mailing Address - Country:US
Mailing Address - Phone:765-584-6600
Mailing Address - Fax:765-584-6503
Practice Address - Street 1:400 SOUTH OAK STREET
Practice Address - Street 2:RANDOLPH MEDICAL CENTER
Practice Address - City:WINCHESTER
Practice Address - State:IN
Practice Address - Zip Code:47394
Practice Address - Country:US
Practice Address - Phone:765-584-6600
Practice Address - Fax:765-584-6503
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-04
Last Update Date:2021-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71007164A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily