Provider Demographics
NPI:1679823090
Name:KEETH, LACEY DANIELLE (MSN, FNP-C)
Entity Type:Individual
Prefix:MRS
First Name:LACEY
Middle Name:DANIELLE
Last Name:KEETH
Suffix:
Gender:F
Credentials:MSN, FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1643 CARTER STREET
Mailing Address - Street 2:SUITE #1
Mailing Address - City:VIDALIA
Mailing Address - State:LA
Mailing Address - Zip Code:71373
Mailing Address - Country:US
Mailing Address - Phone:318-336-8707
Mailing Address - Fax:318-336-8876
Practice Address - Street 1:1643 CARTER STREET
Practice Address - Street 2:SUITE #1
Practice Address - City:VIDALIA
Practice Address - State:LA
Practice Address - Zip Code:71373
Practice Address - Country:US
Practice Address - Phone:318-336-8707
Practice Address - Fax:318-336-8876
Is Sole Proprietor?:No
Enumeration Date:2012-09-12
Last Update Date:2021-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR872599363LF0000X
LAAP09734363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2460561Medicaid