Provider Demographics
NPI:1063001832
Name:MYERS, LACEY
Entity Type:Individual
Prefix:
First Name:LACEY
Middle Name:
Last Name:MYERS
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 1:601 E DIXIE AVE
Mailing Address - Street 2:
Mailing Address - City:LEESBURG
Mailing Address - State:FL
Mailing Address - Zip Code:34748-5953
Mailing Address - Country:US
Mailing Address - Phone:352-728-2404
Mailing Address - Fax:352-787-7401
Practice Address - Street 1:601 E DIXIE AVE
Practice Address - Street 2:
Practice Address - City:LEESBURG
Practice Address - State:FL
Practice Address - Zip Code:34748-5953
Practice Address - Country:US
Practice Address - Phone:352-728-2404
Practice Address - Fax:352-787-7401
Is Sole Proprietor?:No
Enumeration Date:2021-01-15
Last Update Date:2023-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11011012363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily