Healthcare Provider Details

I. General information

NPI: 1568124048
Provider Name (Legal Business Name): LACEY NICOLE SANFORD NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/12/2021
Last Update Date: 06/04/2024
Certification Date: 06/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7622 LOUIS PASTEUR DR STE 201
SAN ANTONIO TX
78229-4019
US

IV. Provider business mailing address

7622 LOUIS PASTEUR DR STE 201
SAN ANTONIO TX
78229-4019
US

V. Phone/Fax

Practice location:
  • Phone: 210-732-3668
  • Fax: 210-732-3338
Mailing address:
  • Phone: 210-732-3668
  • Fax: 210-732-3338

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number1056684
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: