Provider Demographics
NPI:1639593718
Name:WILLIAMS, LACEY
Entity Type:Individual
Prefix:
First Name:LACEY
Middle Name:
Last Name:WILLIAMS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4029 43RD ST APT 201
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92105-1594
Mailing Address - Country:US
Mailing Address - Phone:619-581-8676
Mailing Address - Fax:
Practice Address - Street 1:4029 43RD ST APT 201
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92105-1594
Practice Address - Country:US
Practice Address - Phone:619-581-8676
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-10
Last Update Date:2014-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA225759164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse