Provider Demographics
NPI:1740792431
Name:LACY, MICHELLE RANAE (APRN-CNM)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:RANAE
Last Name:LACY
Suffix:
Gender:F
Credentials:APRN-CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6600 BLACKBERRY RD
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73034-9421
Mailing Address - Country:US
Mailing Address - Phone:405-715-3926
Mailing Address - Fax:
Practice Address - Street 1:6600 BLACKBERRY RD
Practice Address - Street 2:
Practice Address - City:EDMOND
Practice Address - State:OK
Practice Address - Zip Code:73034-9421
Practice Address - Country:US
Practice Address - Phone:405-715-3926
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-02
Last Update Date:2022-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK107130363L00000X
OKR0107030363LX0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LX0001XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerObstetrics & Gynecology
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner