Healthcare Provider Details

I. General information

NPI: 1104366228
Provider Name (Legal Business Name): LACEY R VANEMBURG CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LACEY R GAMMILL

II. Dates (important events)

Enumeration Date: 03/08/2017
Last Update Date: 11/15/2024
Certification Date: 11/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

525 BRANSON LANDING BLVD
BRANSON MO
65616-2052
US

IV. Provider business mailing address

PO BOX 9007
SPRINGFIELD MO
65808-9007
US

V. Phone/Fax

Practice location:
  • Phone: 417-239-3392
  • Fax:
Mailing address:
  • Phone: 417-875-3000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberR085616
License Number StateAR
# 2
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number2018001344
License Number StateMO
# 3
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberCO03204
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: