Provider Demographics
NPI:1053424457
Name:PUCKETT, LACEY DILLARD (OD)
Entity type:Individual
Prefix:DR
First Name:LACEY
Middle Name:DILLARD
Last Name:PUCKETT
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Gender:F
Credentials:OD
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Mailing Address - Street 1:3001 KNOXVILLE CENTER DR
Mailing Address - Street 2:SUITE 2294
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37924-5044
Mailing Address - Country:US
Mailing Address - Phone:865-544-1677
Mailing Address - Fax:865-525-3467
Practice Address - Street 1:3001 KNOXVILLE CENTER DR
Practice Address - Street 2:SUITE 2294
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37924-5044
Practice Address - Country:US
Practice Address - Phone:865-544-1677
Practice Address - Fax:865-525-3467
Is Sole Proprietor?:No
Enumeration Date:2006-08-17
Last Update Date:2017-09-26
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
TN2667152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN39470652Medicare PIN