Provider Demographics
NPI:1104366228
Name:VANEMBURG, LACEY R (CRNA)
Entity Type:Individual
Prefix:
First Name:LACEY
Middle Name:R
Last Name:VANEMBURG
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:LACEY
Other - Middle Name:R
Other - Last Name:GAMMILL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 9007
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65808-9007
Mailing Address - Country:US
Mailing Address - Phone:417-875-3000
Mailing Address - Fax:
Practice Address - Street 1:525 BRANSON LANDING BLVD
Practice Address - Street 2:
Practice Address - City:BRANSON
Practice Address - State:MO
Practice Address - Zip Code:65616-2052
Practice Address - Country:US
Practice Address - Phone:417-239-3392
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-08
Last Update Date:2020-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARR085616163W00000X
ARCO03204367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO910051138Medicaid