Provider Demographics
NPI:1114448917
Name:POTTER, LACEY
Entity Type:Individual
Prefix:
First Name:LACEY
Middle Name:
Last Name:POTTER
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:PO BOX 715
Mailing Address - Street 2:
Mailing Address - City:ADA
Mailing Address - State:OK
Mailing Address - Zip Code:74821-0715
Mailing Address - Country:US
Mailing Address - Phone:580-235-3138
Mailing Address - Fax:
Practice Address - Street 1:15881 COUNTY ROAD 3590
Practice Address - Street 2:
Practice Address - City:ADA
Practice Address - State:OK
Practice Address - Zip Code:74820-0483
Practice Address - Country:US
Practice Address - Phone:580-235-3138
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-30
Last Update Date:2017-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist