Provider Demographics
NPI:1639467806
Name:NELSON, LACEY RENEE (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:LACEY
Middle Name:RENEE
Last Name:NELSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:LACEY
Other - Middle Name:RENEE
Other - Last Name:BRYAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:1950 DIAMOND PARKWAY
Mailing Address - Street 2:SUITE 100
Mailing Address - City:N. KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64116
Mailing Address - Country:US
Mailing Address - Phone:816-561-3003
Mailing Address - Fax:816-889-1584
Practice Address - Street 1:1950 DIAMOND PARKWAY
Practice Address - Street 2:SUITE 100
Practice Address - City:N. KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64116
Practice Address - Country:US
Practice Address - Phone:816-561-3003
Practice Address - Fax:816-889-1584
Is Sole Proprietor?:No
Enumeration Date:2011-07-21
Last Update Date:2024-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2015004697363AS0400X, 363AS0400X
KS15-01604363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOMA6490002Medicare PIN