Provider Demographics
NPI:1851816656
Name:MAUL, LACEY DIANE (ENP, FNP)
Entity Type:Individual
Prefix:MRS
First Name:LACEY
Middle Name:DIANE
Last Name:MAUL
Suffix:
Gender:F
Credentials:ENP, FNP
Other - Prefix:
Other - First Name:LACEY
Other - Middle Name:DIANE
Other - Last Name:MEHAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:16776 HAREWOOD DR E
Mailing Address - Street 2:
Mailing Address - City:NOBLESVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46060-4047
Mailing Address - Country:US
Mailing Address - Phone:317-313-1922
Mailing Address - Fax:
Practice Address - Street 1:1907 W SYCAMORE ST
Practice Address - Street 2:
Practice Address - City:KOKOMO
Practice Address - State:IN
Practice Address - Zip Code:46901-5148
Practice Address - Country:US
Practice Address - Phone:765-456-5433
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-14
Last Update Date:2017-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
INF06170594207PE0004X
INE08170009363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services