Provider Demographics
NPI:1043834302
Name:WATSON, LACEY ELIZABETH (FNP)
Entity Type:Individual
Prefix:
First Name:LACEY
Middle Name:ELIZABETH
Last Name:WATSON
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1860 HOWE AVE STE 440
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95825-1098
Mailing Address - Country:US
Mailing Address - Phone:916-454-2345
Mailing Address - Fax:
Practice Address - Street 1:3710 J ST STE 201
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95816-5519
Practice Address - Country:US
Practice Address - Phone:916-454-2345
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-02
Last Update Date:2021-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95014622363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA95014622OtherNP LICENSE