Healthcare Provider Details

I. General information

NPI: 1215228010
Provider Name (Legal Business Name): LACEY A NICOL CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/27/2011
Last Update Date: 01/31/2023
Certification Date: 01/31/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

818 N 8TH ST
CHARITON IA
50049-1336
US

IV. Provider business mailing address

818 N 8TH ST
CHARITON IA
50049-1336
US

V. Phone/Fax

Practice location:
  • Phone: 641-203-9538
  • Fax:
Mailing address:
  • Phone: 641-203-9538
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberD-129518
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: