Provider Demographics
NPI:1841703089
Name:LACEFIELD, CORTNEY LYNN
Entity type:Individual
Prefix:
First Name:CORTNEY
Middle Name:LYNN
Last Name:LACEFIELD
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 1:4300 BLEVINS GAP RD
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40272-2072
Mailing Address - Country:US
Mailing Address - Phone:502-376-3696
Mailing Address - Fax:
Practice Address - Street 1:5129 DIXIE HWY STE 201
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40216-1727
Practice Address - Country:US
Practice Address - Phone:502-430-6223
Practice Address - Fax:502-369-5229
Is Sole Proprietor?:No
Enumeration Date:2017-11-09
Last Update Date:2019-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3011251363LF0000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100583060Medicaid