Provider Demographics
NPI:1417257171
Name:FLICK, LACEY L (CRNA)
Entity Type:Individual
Prefix:
First Name:LACEY
Middle Name:L
Last Name:FLICK
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 22926
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39225-2926
Mailing Address - Country:US
Mailing Address - Phone:713-400-2990
Mailing Address - Fax:713-400-2993
Practice Address - Street 1:1635 NORTH LOOP W
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77008-1532
Practice Address - Country:US
Practice Address - Phone:713-400-2990
Practice Address - Fax:713-400-2993
Is Sole Proprietor?:No
Enumeration Date:2010-10-28
Last Update Date:2018-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX86162367500000X
TXAP119855363L00000X
TXRN723835163W00000X
TX723835367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX723835OtherRN LICENSE
TX280605102Medicaid