Provider Demographics
NPI:1851549448
Name:LACEY, MARYLOIS (APRN)
Entity Type:Individual
Prefix:MRS
First Name:MARYLOIS
Middle Name:
Last Name:LACEY
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12103 OPAL CREEK DR
Mailing Address - Street 2:
Mailing Address - City:PEARLAND
Mailing Address - State:TX
Mailing Address - Zip Code:77584-1650
Mailing Address - Country:US
Mailing Address - Phone:713-791-1414
Mailing Address - Fax:714-794-7917
Practice Address - Street 1:2002 HOLCOMBE BLVD
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77030-4211
Practice Address - Country:US
Practice Address - Phone:713-791-1414
Practice Address - Fax:713-794-7917
Is Sole Proprietor?:No
Enumeration Date:2008-09-08
Last Update Date:2008-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO131383364SP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SP0808XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health