Provider Demographics
NPI:1720455660
Name:WILSON, LACEY KAY (FNP)
Entity Type:Individual
Prefix:
First Name:LACEY
Middle Name:KAY
Last Name:WILSON
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2801 ST ANTHONY WAY
Mailing Address - Street 2:
Mailing Address - City:PENDLETON
Mailing Address - State:OR
Mailing Address - Zip Code:97801-3800
Mailing Address - Country:US
Mailing Address - Phone:541-966-0535
Mailing Address - Fax:541-278-4597
Practice Address - Street 1:3001 ST ANTHONY WAY
Practice Address - Street 2:
Practice Address - City:PENDLETON
Practice Address - State:OR
Practice Address - Zip Code:97801
Practice Address - Country:US
Practice Address - Phone:541-966-0535
Practice Address - Fax:541-278-4597
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-26
Last Update Date:2019-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR201506113NP-PP261QR1300X
OR201506113NPPP363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500717784Medicaid