Provider Demographics
NPI:1245782549
Name:PREVALLET, LACEY R (FNP-BC)
Entity Type:Individual
Prefix:MRS
First Name:LACEY
Middle Name:R
Last Name:PREVALLET
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:MS
Other - First Name:LACEY
Other - Middle Name:R
Other - Last Name:HERMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:750 CLOVER LN
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:MO
Mailing Address - Zip Code:63640-3336
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:530 N MIDDLE ST
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:MO
Practice Address - Zip Code:63640-1570
Practice Address - Country:US
Practice Address - Phone:573-756-3000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-11-03
Last Update Date:2017-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2011032659163WP0809X
MO2017002573363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163WP0809XNursing Service ProvidersRegistered NursePsychiatric/Mental Health, Adult
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1245782549Medicaid
MO1245782549Medicaid