Provider Demographics
NPI:1568124048
Name:SANFORD, LACEY NICOLE (NP)
Entity Type:Individual
Prefix:MS
First Name:LACEY
Middle Name:NICOLE
Last Name:SANFORD
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4330 MEDICAL DR STE 500
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78229-3318
Mailing Address - Country:US
Mailing Address - Phone:210-558-0122
Mailing Address - Fax:
Practice Address - Street 1:4330 MEDICAL DR STE 500
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78229-3318
Practice Address - Country:US
Practice Address - Phone:210-558-0122
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-12
Last Update Date:2021-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1056684363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner