1790377687 NPI number — MRS. LACEY LYNN MCCLURE AGACNP-BC

Table of content: MRS. LACEY LYNN MCCLURE AGACNP-BC (NPI 1790377687)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790377687 NPI number — MRS. LACEY LYNN MCCLURE AGACNP-BC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MCCLURE
Provider First Name:
LACEY
Provider Middle Name:
LYNN
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
AGACNP-BC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
RICHOUX
Provider Other First Name:
LACEY
Provider Other Middle Name:
LYNN
Provider Other Name Prefix Text:
MS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
RN
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1790377687
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/13/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
18333 EGRET BAY BLVD STE 140
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HOUSTON
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
77058-3239
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
281-332-3001
Provider Business Mailing Address Fax Number:
281-332-3005

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
110 E MEDICAL CENTER BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WEBSTER
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
77598-4301
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
832-224-9500
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/11/2021

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: 363LA2100X , with the licence number:  1029696 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 424368502 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 424368501 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 8PW475 . This is a "BCBS" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".