MEDICARE: LACEY WHATLEY NP-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	APRN11004096	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1548805856
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LACEY WHATLEY NP-C

Provider Business Mailing Address
First Line	:	210 ARIANA PL
Second Line	:
City	:	AUBURNDALE
State	:	FL
Zip	:	33823-2534
Country	:	US
Telephone Number	:	863-712-2172
Fax Number	:

Provider Business Practice Location Address
First Line	:	2433 STATE ROAD 60 E
Second Line	:
City	:	LAKE WALES
State	:	FL
Zip	:	33898-5122
Country	:	US
Telephone Number	:	863-712-2172
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/11/2019
Last Update Date	:	11/11/2019

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