Provider Demographics
NPI:1083056915
Name:VASILAKIS, LACEY WHATLEY (FNP-C)
Entity Type:Individual
Prefix:
First Name:LACEY
Middle Name:WHATLEY
Last Name:VASILAKIS
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:MISS
Other - First Name:LACEY
Other - Middle Name:J
Other - Last Name:WHATLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:PO BOX 122579 DEPT 2579
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75312-2579
Mailing Address - Country:US
Mailing Address - Phone:337-494-2921
Mailing Address - Fax:337-494-6523
Practice Address - Street 1:2770 3RD AVE STE 210
Practice Address - Street 2:
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70601-0404
Practice Address - Country:US
Practice Address - Phone:337-494-6768
Practice Address - Fax:337-494-6792
Is Sole Proprietor?:No
Enumeration Date:2013-07-19
Last Update Date:2022-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAAP07810363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2369385Medicaid
LAAP07810OtherSTATE LICENSE
LA2369385Medicaid