Provider Demographics
NPI:1396579124
Name:BOLDUC, LACEY
Entity type:Individual
Prefix:
First Name:LACEY
Middle Name:
Last Name:BOLDUC
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:LACEY
Other - Middle Name:
Other - Last Name:BROWN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:528 COTTAGE ST NE STE 401
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97301-3861
Mailing Address - Country:US
Mailing Address - Phone:503-583-4319
Mailing Address - Fax:503-343-3331
Practice Address - Street 1:528 COTTAGE ST NE STE 401
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97301-3861
Practice Address - Country:US
Practice Address - Phone:503-583-4319
Practice Address - Fax:503-343-3331
Is Sole Proprietor?:No
Enumeration Date:2024-08-26
Last Update Date:2024-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program