Provider Demographics
NPI:1417733924
Name:LACEY, SIERRA VICTORIA
Entity Type:Individual
Prefix:
First Name:SIERRA
Middle Name:VICTORIA
Last Name:LACEY
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 1:3000 N GRAND BLVD
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73107-1818
Mailing Address - Country:US
Mailing Address - Phone:405-632-6688
Mailing Address - Fax:
Practice Address - Street 1:1237 ALAMEDA ST
Practice Address - Street 2:
Practice Address - City:NORMAN
Practice Address - State:OK
Practice Address - Zip Code:73071-3006
Practice Address - Country:US
Practice Address - Phone:668-840-5632
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-31
Last Update Date:2023-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK214872363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics