MEDICARE: MRS. SUSAN GENE LACEY RNC MSN WHNP

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	363L00000X	Nurse Practitioner	129117	MO

General Provider Information

NPI Number	:	1871693853
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. SUSAN GENE LACEY RNC MSN WHNP

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

Provider Business Practice Location Address
First Line	:	1905 W 32ND STREET
Second Line	:	SUITE 306
City	:	JOPLIN
State	:	MO
Zip	:	64804-1512
Country	:	US
Telephone Number	:	417-624-2111
Fax Number	:	417-624-1551

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

Provider Enumeration Date	:	09/22/2006
Last Update Date	:	02/17/2012

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