Provider Demographics
NPI:1689912909
Name:LACEY, OUIDA MICHELLE (FNP-C)
Entity Type:Individual
Prefix:
First Name:OUIDA
Middle Name:MICHELLE
Last Name:LACEY
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1305 WONDER WORLD DR STE 300
Mailing Address - Street 2:
Mailing Address - City:SAN MARCOS
Mailing Address - State:TX
Mailing Address - Zip Code:78666-7541
Mailing Address - Country:US
Mailing Address - Phone:512-396-3545
Mailing Address - Fax:512-396-1349
Practice Address - Street 1:1305 WONDER WORLD DR STE 300
Practice Address - Street 2:
Practice Address - City:SAN MARCOS
Practice Address - State:TX
Practice Address - Zip Code:78666-7541
Practice Address - Country:US
Practice Address - Phone:512-396-3545
Practice Address - Fax:512-396-1349
Is Sole Proprietor?:No
Enumeration Date:2013-01-21
Last Update Date:2021-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX767493363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
P02239928OtherRR MEDICARE
297946YMG2OtherMEDICARE
TX192390601Medicaid