Provider Demographics
NPI:1154868024
Name:GOTTULA, LACEY
Entity Type:Individual
Prefix:
First Name:LACEY
Middle Name:
Last Name:GOTTULA
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 1:8445 ANDERMATT DR
Mailing Address - Street 2:
Mailing Address - City:LINCOLN
Mailing Address - State:NE
Mailing Address - Zip Code:68526-9746
Mailing Address - Country:US
Mailing Address - Phone:402-328-4700
Mailing Address - Fax:
Practice Address - Street 1:8445 ANDERMATT DR
Practice Address - Street 2:
Practice Address - City:LINCOLN
Practice Address - State:NE
Practice Address - Zip Code:68526-9746
Practice Address - Country:US
Practice Address - Phone:402-328-4700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-01-30
Last Update Date:2017-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE74152163W00000X
NE112176363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse