Provider Demographics
NPI:1649468265
Name:KRAACK, LACEY E (RDMS, RVT, RT(R))
Entity type:Individual
Prefix:
First Name:LACEY
Middle Name:E
Last Name:KRAACK
Suffix:
Gender:F
Credentials:RDMS, RVT, RT(R)
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 63
Mailing Address - Street 2:
Mailing Address - City:LAKE HUNTINGTON
Mailing Address - State:NY
Mailing Address - Zip Code:12752-0063
Mailing Address - Country:US
Mailing Address - Phone:210-573-3327
Mailing Address - Fax:
Practice Address - Street 1:2629 N 7TH ST
Practice Address - Street 2:
Practice Address - City:SHEBOYGAN
Practice Address - State:WI
Practice Address - Zip Code:53083-4932
Practice Address - Country:US
Practice Address - Phone:920-451-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-10-09
Last Update Date:2007-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
346578247100000X
947552471S1302X, 2471V0105X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2471S1302XTechnologists, Technicians & Other Technical Service ProvidersRadiologic TechnologistSonography
No247100000XTechnologists, Technicians & Other Technical Service ProvidersRadiologic Technologist
No2471V0105XTechnologists, Technicians & Other Technical Service ProvidersRadiologic TechnologistVascular Sonography