Healthcare Provider Details

I. General information

NPI: 1063196905
Provider Name (Legal Business Name): LACEY VATLAND APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/12/2023
Last Update Date: 07/05/2023
Certification Date: 07/05/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1155 35TH LN STE 201A
VERO BEACH FL
32960-6537
US

IV. Provider business mailing address

10140 CENTURION PKWY N
JACKSONVILLE FL
32256-0532
US

V. Phone/Fax

Practice location:
  • Phone: 772-562-5662
  • Fax:
Mailing address:
  • Phone: 904-697-4100
  • Fax: 904-697-5102

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberAPRN11027159
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: