Healthcare Provider Details

I. General information

NPI: 1245782549
Provider Name (Legal Business Name): LACEY R PREVALLET FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MS. LACEY R HERMAN

II. Dates (important events)

Enumeration Date: 11/03/2016
Last Update Date: 02/15/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

530 N MIDDLE ST
FARMINGTON MO
63640-1570
US

IV. Provider business mailing address

750 CLOVER LN
FARMINGTON MO
63640-3336
US

V. Phone/Fax

Practice location:
  • Phone: 573-756-3000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WP0809X
TaxonomyAdult Psychiatric/Mental Health Registered Nurse
License Number2011032659
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number2017002573
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: