Provider Demographics
NPI:1891334603
Name:COFFEY, LACEY DIANE (APRN)
Entity Type:Individual
Prefix:
First Name:LACEY
Middle Name:DIANE
Last Name:COFFEY
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 1:504 N REO ST
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33609-1013
Mailing Address - Country:US
Mailing Address - Phone:813-330-1373
Mailing Address - Fax:813-864-4436
Practice Address - Street 1:407 W DANIELDALE RD STE 100
Practice Address - Street 2:
Practice Address - City:DUNCANVILLE
Practice Address - State:TX
Practice Address - Zip Code:75137-3927
Practice Address - Country:US
Practice Address - Phone:214-941-3192
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-26
Last Update Date:2020-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP143271363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily