Provider Demographics
NPI:1073390621
Name:LACY CLAYTON WELLNESS
Entity Type:Organization
Organization Name:LACY CLAYTON WELLNESS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LACY
Authorized Official - Middle Name:RAE
Authorized Official - Last Name:CLAYTON
Authorized Official - Suffix:
Authorized Official - Credentials:DNP PMHNP-BC
Authorized Official - Phone:267-944-6220
Mailing Address - Street 1:102 WAVERLY RD
Mailing Address - Street 2:
Mailing Address - City:WYNCOTE
Mailing Address - State:PA
Mailing Address - Zip Code:19095-1322
Mailing Address - Country:US
Mailing Address - Phone:267-944-6220
Mailing Address - Fax:
Practice Address - Street 1:102 WAVERLY RD
Practice Address - Street 2:
Practice Address - City:WYNCOTE
Practice Address - State:PA
Practice Address - Zip Code:19095-1322
Practice Address - Country:US
Practice Address - Phone:267-944-6220
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-09-08
Last Update Date:2023-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty