Provider Demographics
NPI:1114771144
Name:FOX, LACEY
Entity Type:Individual
Prefix:
First Name:LACEY
Middle Name:
Last Name:FOX
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 1:9612 E OLIVE RD
Mailing Address - Street 2:
Mailing Address - City:WHEELER
Mailing Address - State:MI
Mailing Address - Zip Code:48662-9745
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1234 E BROOMFIELD ST
Practice Address - Street 2:
Practice Address - City:MT PLEASANT
Practice Address - State:MI
Practice Address - Zip Code:48858-4491
Practice Address - Country:US
Practice Address - Phone:989-817-7915
Practice Address - Fax:989-423-0630
Is Sole Proprietor?:No
Enumeration Date:2024-04-16
Last Update Date:2024-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist