Provider Demographics
NPI:1679113856
Name:LACEY, ALICIA MARIE
Entity Type:Individual
Prefix:
First Name:ALICIA
Middle Name:MARIE
Last Name:LACEY
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 1:516 S HORNE ST
Mailing Address - Street 2:
Mailing Address - City:OCEANSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92054-4251
Mailing Address - Country:US
Mailing Address - Phone:760-420-4669
Mailing Address - Fax:
Practice Address - Street 1:2325 CALIFORNIA ST
Practice Address - Street 2:
Practice Address - City:OCEANSIDE
Practice Address - State:CA
Practice Address - Zip Code:92054-5711
Practice Address - Country:US
Practice Address - Phone:760-212-1919
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-15
Last Update Date:2020-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA6742059OtherDRIVER LICENSE