Healthcare Provider Details

I. General information

NPI: 1851119267
Provider Name (Legal Business Name): LACEY UPHAUS FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LACEY SIMPSON

II. Dates (important events)

Enumeration Date: 10/03/2024
Last Update Date: 03/25/2025
Certification Date: 03/25/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

618 N BENTON AVE
SPRINGFIELD MO
65806-1102
US

IV. Provider business mailing address

440 E TAMPA ST
SPRINGFIELD MO
65806-1131
US

V. Phone/Fax

Practice location:
  • Phone: 417-831-0150
  • Fax: 417-865-3479
Mailing address:
  • Phone: 417-831-0150
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number2024040275
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: