Provider Demographics
NPI:1679946008
Name:LACEY, STACEY ELIZABETH
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:ELIZABETH
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 1:1401 MEDICAL PKWY
Mailing Address - Street 2:BLDG B, STE 205
Mailing Address - City:CEDAR PARK
Mailing Address - State:TX
Mailing Address - Zip Code:78613-7763
Mailing Address - Country:US
Mailing Address - Phone:512-528-7401
Mailing Address - Fax:512-528-7402
Practice Address - Street 1:300 SINGLETON RIDGE RD
Practice Address - Street 2:
Practice Address - City:CONWAY
Practice Address - State:SC
Practice Address - Zip Code:29526-9142
Practice Address - Country:US
Practice Address - Phone:843-347-8175
Practice Address - Fax:432-346-7598
Is Sole Proprietor?:No
Enumeration Date:2015-11-06
Last Update Date:2020-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX758324163W00000X
TXAP129484363LG0600X
SCAP129484363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No163W00000XNursing Service ProvidersRegistered Nurse
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology