Provider Demographics
NPI:1780611459
Name:KINNEY, LACY C (PA-C)
Entity type:Individual
Prefix:MS
First Name:LACY
Middle Name:C
Last Name:KINNEY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:149 WALNUT GROVE CHURCH RD
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:TN
Mailing Address - Zip Code:37321-7925
Mailing Address - Country:US
Mailing Address - Phone:423-775-5512
Mailing Address - Fax:423-775-0155
Practice Address - Street 1:149 WALNUT GROVE CHURCH RD
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:TN
Practice Address - Zip Code:37321-7925
Practice Address - Country:US
Practice Address - Phone:423-775-5512
Practice Address - Fax:423-775-0155
Is Sole Proprietor?:No
Enumeration Date:2006-06-27
Last Update Date:2013-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNPA1301363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN4118477OtherBCBS OF TENNESSEE
AL891012560Medicaid
TNP00308205OtherRAILROAD MEDICARE
AL891012560Medicaid
TNQ65197Medicare UPIN