Provider Demographics
NPI:1811481294
Name:DIETRICH, LACEY LEIGH (ARNP)
Entity type:Individual
Prefix:MRS
First Name:LACEY
Middle Name:LEIGH
Last Name:DIETRICH
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:LACEY
Other - Middle Name:LEIGH
Other - Last Name:BAYSINGER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1842 SENTRY OAK CT
Mailing Address - Street 2:
Mailing Address - City:FLEMING ISLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32003-3764
Mailing Address - Country:US
Mailing Address - Phone:904-446-6789
Mailing Address - Fax:
Practice Address - Street 1:1 SHIRCLIFF WAY
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32204-4748
Practice Address - Country:US
Practice Address - Phone:904-308-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-19
Last Update Date:2023-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP9316073363LF0000X
FLAPRN9316073363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily