Provider Demographics
NPI:1821461344
Name:MYERS, LACEY JO I (ARNP)
Entity Type:Individual
Prefix:
First Name:LACEY
Middle Name:JO
Last Name:MYERS
Suffix:I
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2213 GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50312-5305
Mailing Address - Country:US
Mailing Address - Phone:515-237-3974
Mailing Address - Fax:515-883-2692
Practice Address - Street 1:1325 NE 31ST ST
Practice Address - Street 2:
Practice Address - City:ANKENY
Practice Address - State:IA
Practice Address - Zip Code:50021-6695
Practice Address - Country:US
Practice Address - Phone:515-279-1959
Practice Address - Fax:515-289-0888
Is Sole Proprietor?:No
Enumeration Date:2015-11-05
Last Update Date:2016-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAA128569363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
IAI43700006OtherMEDICARE PTAN MMP
IAIB3557001OtherMEDICARE PTAN TEAMMD