Provider Demographics
NPI:1538488143
Name:LACEY, JENNIFER (CRNP)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:LACEY
Suffix:
Gender:F
Credentials:CRNP
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 202712
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75320-2712
Mailing Address - Country:US
Mailing Address - Phone:866-961-6774
Mailing Address - Fax:781-937-6442
Practice Address - Street 1:315 W HICKORY ST
Practice Address - Street 2:
Practice Address - City:SYLACAUGA
Practice Address - State:AL
Practice Address - Zip Code:35150-2913
Practice Address - Country:US
Practice Address - Phone:406-600-9186
Practice Address - Fax:781-937-6442
Is Sole Proprietor?:No
Enumeration Date:2010-05-21
Last Update Date:2010-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-107400363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner