Provider Demographics
NPI:1548805856
Name:WHATLEY, LACEY (NP-C)
Entity Type:Individual
Prefix:
First Name:LACEY
Middle Name:
Last Name:WHATLEY
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:210 ARIANA PL
Mailing Address - Street 2:
Mailing Address - City:AUBURNDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33823-2534
Mailing Address - Country:US
Mailing Address - Phone:863-712-2172
Mailing Address - Fax:
Practice Address - Street 1:2433 STATE ROAD 60 E
Practice Address - Street 2:
Practice Address - City:LAKE WALES
Practice Address - State:FL
Practice Address - Zip Code:33898-5122
Practice Address - Country:US
Practice Address - Phone:863-712-2172
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-11
Last Update Date:2019-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11004096207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine