Healthcare Provider Details

I. General information

NPI: 1134052368
Provider Name (Legal Business Name): LACEY ANN GADDIS RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LACEY ANN LAUSEN

II. Dates (important events)

Enumeration Date: 06/06/2026
Last Update Date: 06/06/2026
Certification Date: 06/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

308 7TH ST NW
BYRON MN
55920-1349
US

IV. Provider business mailing address

308 7TH ST NW
BYRON MN
55920-1349
US

V. Phone/Fax

Practice location:
  • Phone: 907-978-5067
  • Fax:
Mailing address:
  • Phone: 907-978-5067
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WE0003X
TaxonomyEmergency Registered Nurse
License Number2519048
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: