Provider Demographics
NPI:1376825265
Name:MILLER, LACEY (LPN)
Entity Type:Individual
Prefix:
First Name:LACEY
Middle Name:
Last Name:MILLER
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:697 171ST ST
Mailing Address - Street 2:
Mailing Address - City:LAKE WILSON
Mailing Address - State:MN
Mailing Address - Zip Code:56151-1047
Mailing Address - Country:US
Mailing Address - Phone:507-227-1776
Mailing Address - Fax:
Practice Address - Street 1:697 171ST ST
Practice Address - Street 2:
Practice Address - City:LAKE WILSON
Practice Address - State:MN
Practice Address - Zip Code:56151-1047
Practice Address - Country:US
Practice Address - Phone:507-227-1776
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-09-15
Last Update Date:2011-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNL 071860-6164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse