Healthcare Provider Details

I. General information

NPI: 1639306749
Provider Name (Legal Business Name): LACEY MAY CARPENTER P.A.C.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/16/2009
Last Update Date: 09/28/2021
Certification Date: 09/28/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17742 BEACH BLVD STE 240
HUNTINGTON BEACH CA
92647-6835
US

IV. Provider business mailing address

17742 BEACH BLVD STE 240
HUNTINGTON BEACH CA
92647-6835
US

V. Phone/Fax

Practice location:
  • Phone: 714-842-0444
  • Fax: 714-842-8444
Mailing address:
  • Phone: 714-842-0444
  • Fax: 714-842-8444

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA60097518
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: