Provider Demographics
NPI:1881157949
Name:MEGORDEN, LACEY (BS)
Entity type:Individual
Prefix:
First Name:LACEY
Middle Name:
Last Name:MEGORDEN
Suffix:
Gender:F
Credentials:BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4222 W EMERALD ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83706-2037
Mailing Address - Country:US
Mailing Address - Phone:208-605-3663
Mailing Address - Fax:
Practice Address - Street 1:4222 W EMERALD ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83706-2037
Practice Address - Country:US
Practice Address - Phone:208-605-3663
Practice Address - Fax:208-605-3663
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-07
Last Update Date:2019-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1Medicaid