Provider Demographics
NPI:1720349772
Name:WILSON-WHITE, LACY J
Entity Type:Individual
Prefix:
First Name:LACY
Middle Name:J
Last Name:WILSON-WHITE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:LACY
Other - Middle Name:J
Other - Last Name:WILSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:914 N CANAL ST
Mailing Address - Street 2:
Mailing Address - City:CARLSBAD
Mailing Address - State:NM
Mailing Address - Zip Code:88220-5110
Mailing Address - Country:US
Mailing Address - Phone:575-885-4836
Mailing Address - Fax:575-887-9579
Practice Address - Street 1:1700 W MAIN ST
Practice Address - Street 2:SUITE A2
Practice Address - City:ARTESIA
Practice Address - State:NM
Practice Address - Zip Code:88210-3711
Practice Address - Country:US
Practice Address - Phone:575-746-8890
Practice Address - Fax:575-746-2383
Is Sole Proprietor?:No
Enumeration Date:2012-06-06
Last Update Date:2012-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator