1871693853 NPI number — MRS. SUSAN GENE LACEY RNC MSN WHNP

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1871693853 NPI number — MRS. SUSAN GENE LACEY RNC MSN WHNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LACEY
Provider First Name:
SUSAN
Provider Middle Name:
GENE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
RNC MSN WHNP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
ELMORE
Provider Other First Name:
SUSAN
Provider Other Middle Name:
GENE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1871693853
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/17/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 2067
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JOPLIN
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
64804-2067
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
417-624-2111
Provider Business Mailing Address Fax Number:
417-624-1551

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1905 W 32ND STREET
Provider Second Line Business Practice Location Address:
SUITE 306
Provider Business Practice Location Address City Name:
JOPLIN
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
64804-1512
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
417-624-2111
Provider Business Practice Location Address Fax Number:
417-624-1551
Provider Enumeration Date:
09/22/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363L00000X , with the licence number:  129117 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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