Provider Demographics
NPI:1235905316
Name:SMITH, LACY NICHOLE
Entity Type:Individual
Prefix:
First Name:LACY
Middle Name:NICHOLE
Last Name:SMITH
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 1:407 CHESTNUT LN
Mailing Address - Street 2:
Mailing Address - City:DANIELS
Mailing Address - State:WV
Mailing Address - Zip Code:25832-9435
Mailing Address - Country:US
Mailing Address - Phone:333-333-3333
Mailing Address - Fax:
Practice Address - Street 1:407 CHESTNUT LN
Practice Address - Street 2:
Practice Address - City:DANIELS
Practice Address - State:WV
Practice Address - Zip Code:25832-9435
Practice Address - Country:US
Practice Address - Phone:333-333-3333
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-11-29
Last Update Date:2023-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant