Provider Demographics
NPI:1629547948
Name:ANDERSON, LACIE JAI (LPN)
Entity Type:Individual
Prefix:
First Name:LACIE
Middle Name:JAI
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6721 NW 124TH TER
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73142-3124
Mailing Address - Country:US
Mailing Address - Phone:405-201-0322
Mailing Address - Fax:
Practice Address - Street 1:6721 NW 124TH TER
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73142-3124
Practice Address - Country:US
Practice Address - Phone:405-201-0322
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-15
Last Update Date:2018-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK60670164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse