Provider Demographics
NPI:1811437064
Name:MARTINEZ, LACEY (ATC LAT)
Entity type:Individual
Prefix:
First Name:LACEY
Middle Name:
Last Name:MARTINEZ
Suffix:
Gender:F
Credentials:ATC LAT
Other - Prefix:
Other - First Name:LACEY
Other - Middle Name:
Other - Last Name:CARLSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:ATC LAT
Mailing Address - Street 1:1600 E EUCLID ST
Mailing Address - Street 2:
Mailing Address - City:MCPHERSON
Mailing Address - State:KS
Mailing Address - Zip Code:67460-3847
Mailing Address - Country:US
Mailing Address - Phone:620-474-0427
Mailing Address - Fax:
Practice Address - Street 1:1600 E EUCLID ST
Practice Address - Street 2:
Practice Address - City:MCPHERSON
Practice Address - State:KS
Practice Address - Zip Code:67460-3847
Practice Address - Country:US
Practice Address - Phone:620-474-0427
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-06
Last Update Date:2017-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS24-008462255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer