Healthcare Provider Details

I. General information

NPI: 1710362520
Provider Name (Legal Business Name): LACEY CARLSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/22/2015
Last Update Date: 10/31/2026
Certification Date: 10/31/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

140 E RIDGEWOOD AVE STE 415S
PARAMUS NJ
07652-3917
US

IV. Provider business mailing address

5410 MARYLAND WAY STE 400
BRENTWOOD TN
37027-8087
US

V. Phone/Fax

Practice location:
  • Phone: 855-212-2273
  • Fax: 629-240-6003
Mailing address:
  • Phone: 855-212-2273
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number26NJ00579200
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: