Healthcare Provider Details

I. General information

NPI: 1174946032
Provider Name (Legal Business Name): LACEY ANGELLE THOMAS APRN, NNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: LACEY RENEE ANGELLE APRN, NNP-BC

II. Dates (important events)

Enumeration Date: 01/29/2014
Last Update Date: 08/22/2024
Certification Date: 08/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4600 AMBASSADOR CAFFERY PKWY
LAFAYETTE LA
70508-6902
US

IV. Provider business mailing address

5959 S SHERWOOD FOREST BLVD
BATON ROUGE LA
70816-6038
US

V. Phone/Fax

Practice location:
  • Phone: 337-470-5634
  • Fax:
Mailing address:
  • Phone: 337-470-5634
  • Fax: 225-765-9196

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WN0002X
TaxonomyNeonatal Intensive Care Registered Nurse
License NumberRN119251
License Number StateLA
# 2
Primary TaxonomyY
Taxonomy Code363LN0000X
TaxonomyNeonatal Nurse Practitioner
License NumberAP07765
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: