Provider Demographics
NPI:1528548518
Name:WILSON, LACI NICOLE
Entity Type:Individual
Prefix:
First Name:LACI
Middle Name:NICOLE
Last Name:WILSON
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 1:9104 ARMAN DR
Mailing Address - Street 2:
Mailing Address - City:YUKON
Mailing Address - State:OK
Mailing Address - Zip Code:73099-5264
Mailing Address - Country:US
Mailing Address - Phone:580-216-5224
Mailing Address - Fax:
Practice Address - Street 1:9104 ARMAN DR
Practice Address - Street 2:
Practice Address - City:YUKON
Practice Address - State:OK
Practice Address - Zip Code:73099-5264
Practice Address - Country:US
Practice Address - Phone:580-216-5224
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-19
Last Update Date:2018-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator