Healthcare Provider Details

I. General information

NPI: 1215488721
Provider Name (Legal Business Name): LACEY LYNN NOBLES PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/19/2016
Last Update Date: 05/04/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6560 FANNIN ST SUITE 1842
HOUSTON TX
77030-2761
US

IV. Provider business mailing address

6560 FANNIN ST SUITE 1842
HOUSTON TX
77030-2761
US

V. Phone/Fax

Practice location:
  • Phone: 713-790-2089
  • Fax: 713-794-0576
Mailing address:
  • Phone: 713-790-2089
  • Fax: 713-794-0576

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA10894
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: