Provider Demographics
NPI:1588808687
Name:MADISON, LACIE TARA (CRNP)
Entity Type:Individual
Prefix:MRS
First Name:LACIE
Middle Name:TARA
Last Name:MADISON
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 1:26487 US HIGHWAY 98
Mailing Address - Street 2:
Mailing Address - City:ELBERTA
Mailing Address - State:AL
Mailing Address - Zip Code:36530-2709
Mailing Address - Country:US
Mailing Address - Phone:251-752-7206
Mailing Address - Fax:
Practice Address - Street 1:5151 N 9TH AVE
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32504-8721
Practice Address - Country:US
Practice Address - Phone:850-416-7000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-04-21
Last Update Date:2024-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP9463502363LF0000X
FL9463502207PP0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PP0204XAllopathic & Osteopathic PhysiciansEmergency MedicinePediatric Emergency Medicine
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily