Provider Demographics
NPI:1346511433
Name:SOUR LAKE HEALTH & MEDICAL, PLLC
Entity Type:Organization
Organization Name:SOUR LAKE HEALTH & MEDICAL, PLLC
Other - Org Name:SOUR LAKE HEALTH & MEDICAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:LACEY
Authorized Official - Middle Name:
Authorized Official - Last Name:GUEDRY
Authorized Official - Suffix:
Authorized Official - Credentials:MSN, APRN, FNP-C
Authorized Official - Phone:409-287-4100
Mailing Address - Street 1:PO BOX 429
Mailing Address - Street 2:
Mailing Address - City:SOUR LAKE
Mailing Address - State:TX
Mailing Address - Zip Code:77659-0429
Mailing Address - Country:US
Mailing Address - Phone:409-287-4100
Mailing Address - Fax:409-287-4105
Practice Address - Street 1:689 SIXTH STREET
Practice Address - Street 2:
Practice Address - City:SOUR LAKE
Practice Address - State:TX
Practice Address - Zip Code:77659-1870
Practice Address - Country:US
Practice Address - Phone:409-287-4100
Practice Address - Fax:409-287-4105
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-20
Last Update Date:2019-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX712554363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty