Provider Demographics
NPI:1992358378
Name:SMITH, LACY (FNP-BC, PMHNP-BC)
Entity Type:Individual
Prefix:MS
First Name:LACY
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:FNP-BC, PMHNP-BC
Other - Prefix:MISS
Other - First Name:LACY
Other - Middle Name:
Other - Last Name:MCINTYRE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 178
Mailing Address - Street 2:
Mailing Address - City:SATANTA
Mailing Address - State:KS
Mailing Address - Zip Code:67870-0178
Mailing Address - Country:US
Mailing Address - Phone:620-649-2505
Mailing Address - Fax:669-204-0329
Practice Address - Street 1:1029 E VANDAMENT AVE
Practice Address - Street 2:
Practice Address - City:YUKON
Practice Address - State:OK
Practice Address - Zip Code:73099-4949
Practice Address - Country:US
Practice Address - Phone:405-350-4300
Practice Address - Fax:405-350-4302
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-24
Last Update Date:2024-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS13-127040-052163WM0705X
KS53-78893363LF0000X, 363LP0808X
OK216289363LF0000X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163WM0705XNursing Service ProvidersRegistered NurseMedical-Surgical
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK201236440AMedicaid
KS201291660AMedicaid