Healthcare Provider Details

I. General information

NPI: 1750729174
Provider Name (Legal Business Name): LACEY ALISON KLIEWER APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/07/2013
Last Update Date: 12/03/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2535 E LINCOLN ST
WICHITA KS
67211-3821
US

IV. Provider business mailing address

753 N WEST ST
WICHITA KS
67203-1240
US

V. Phone/Fax

Practice location:
  • Phone: 316-687-9794
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number53-75740-051
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: