Provider Demographics
NPI:1477059376
Name:LACY, ANTWAN EDWARD (FNP-C)
Entity Type:Individual
Prefix:MR
First Name:ANTWAN
Middle Name:EDWARD
Last Name:LACY
Suffix:
Gender:M
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7000 4TH ST N STE A
Mailing Address - Street 2:
Mailing Address - City:SAINT PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33702-5903
Mailing Address - Country:US
Mailing Address - Phone:727-526-3627
Mailing Address - Fax:727-525-3492
Practice Address - Street 1:7000 4TH ST N STE A
Practice Address - Street 2:
Practice Address - City:SAINT PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33702-5903
Practice Address - Country:US
Practice Address - Phone:727-526-3627
Practice Address - Fax:727-525-3492
Is Sole Proprietor?:No
Enumeration Date:2018-04-01
Last Update Date:2021-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9372952363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily