Healthcare Provider Details

I. General information

NPI: 1225954621
Provider Name (Legal Business Name): LACIE C THOMPSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/29/2026
Last Update Date: 06/29/2026
Certification Date: 06/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

123 E AVENUE C
HEAVENER OK
74937-2603
US

IV. Provider business mailing address

39778 STONE RD
HOWE OK
74940-3676
US

V. Phone/Fax

Practice location:
  • Phone: 918-653-2543
  • Fax:
Mailing address:
  • Phone: 918-413-7646
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: