Provider Demographics
NPI:1639306749
Name:CARPENTER, LACEY MAY (PAC)
Entity Type:Individual
Prefix:
First Name:LACEY
Middle Name:MAY
Last Name:CARPENTER
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17742 BEACH BLVD STE 240
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92647-6835
Mailing Address - Country:US
Mailing Address - Phone:714-842-0444
Mailing Address - Fax:714-842-8444
Practice Address - Street 1:17742 BEACH BLVD STE 240
Practice Address - Street 2:
Practice Address - City:HUNTINGTON BEACH
Practice Address - State:CA
Practice Address - Zip Code:92647-6835
Practice Address - Country:US
Practice Address - Phone:714-842-0444
Practice Address - Fax:714-842-8444
Is Sole Proprietor?:No
Enumeration Date:2009-06-16
Last Update Date:2021-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA60097518363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2003083Medicaid
OR500636969Medicaid