Provider Demographics
NPI:1184195232
Name:TIMPERLEY, LACEY
Entity Type:Individual
Prefix:
First Name:LACEY
Middle Name:
Last Name:TIMPERLEY
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 1:1404 WATER ST
Mailing Address - Street 2:
Mailing Address - City:PORT HURON
Mailing Address - State:MI
Mailing Address - Zip Code:48060-4213
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1430 MILITARY ST
Practice Address - Street 2:
Practice Address - City:PORT HURON
Practice Address - State:MI
Practice Address - Zip Code:48060-5912
Practice Address - Country:US
Practice Address - Phone:810-937-6651
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-16
Last Update Date:2018-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704314508163WC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163WC0200XNursing Service ProvidersRegistered NurseCritical Care MedicineGroup - Single Specialty