Provider Demographics
NPI:1578841045
Name:HERALD, LACEY M (PA)
Entity Type:Individual
Prefix:
First Name:LACEY
Middle Name:M
Last Name:HERALD
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1086 TEANECK RD STE 4C
Mailing Address - Street 2:
Mailing Address - City:TEANECK
Mailing Address - State:NJ
Mailing Address - Zip Code:07666-4855
Mailing Address - Country:US
Mailing Address - Phone:201-837-3443
Mailing Address - Fax:201-578-1699
Practice Address - Street 1:1086 TEANECK RD STE 4C
Practice Address - Street 2:
Practice Address - City:TEANECK
Practice Address - State:NJ
Practice Address - Zip Code:07666-4855
Practice Address - Country:US
Practice Address - Phone:201-837-9449
Practice Address - Fax:201-578-1699
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-01
Last Update Date:2021-09-02
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
NJ25MP00259500363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant