Provider Demographics
NPI:1679834857
Name:RAICHE, LACEY JO (FNP)
Entity Type:Individual
Prefix:MRS
First Name:LACEY
Middle Name:JO
Last Name:RAICHE
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3603 SCHNEIDER AVENUE
Mailing Address - Street 2:
Mailing Address - City:MENOMONIE
Mailing Address - State:WI
Mailing Address - Zip Code:54751-5674
Mailing Address - Country:US
Mailing Address - Phone:715-233-6400
Mailing Address - Fax:
Practice Address - Street 1:3603 SCHNEIDER AVENUE
Practice Address - Street 2:
Practice Address - City:MENOMONIE
Practice Address - State:WI
Practice Address - Zip Code:54751-5674
Practice Address - Country:US
Practice Address - Phone:715-233-6400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-04
Last Update Date:2021-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR207746-8363L00000X
WI162013-30363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1679834857Medicaid