Healthcare Provider Details

I. General information

NPI: 1982953261
Provider Name (Legal Business Name): LACIE GRUBBE RN,BSN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/02/2012
Last Update Date: 09/02/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5009 CANA CV
AUSTIN TX
78749-4687
US

IV. Provider business mailing address

5009 CANA CV
AUSTIN TX
78749-4687
US

V. Phone/Fax

Practice location:
  • Phone: 918-504-4376
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0200X
TaxonomyPediatric Registered Nurse
License Number786889
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: