Provider Demographics
NPI:1841485935
Name:CHAVARRIA, LACEY LISS (CRNA)
Entity type:Individual
Prefix:
First Name:LACEY
Middle Name:LISS
Last Name:CHAVARRIA
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:MEDICAL CENTER BLVD
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27157-0001
Mailing Address - Country:US
Mailing Address - Phone:336-878-6000
Mailing Address - Fax:336-878-6010
Practice Address - Street 1:601 N ELM ST
Practice Address - Street 2:
Practice Address - City:HIGH POINT
Practice Address - State:NC
Practice Address - Zip Code:27262-4331
Practice Address - Country:US
Practice Address - Phone:336-878-6000
Practice Address - Fax:336-878-6010
Is Sole Proprietor?:No
Enumeration Date:2007-09-11
Last Update Date:2025-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC181589163W00000X
NC078220367500000X
NC3465367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8053006Medicaid
NC2621658Medicare PIN