Healthcare Provider Details

I. General information

NPI: 1669093175
Provider Name (Legal Business Name): LACEY RENEE ANDERSON CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LACEY RENEE GROFF

II. Dates (important events)

Enumeration Date: 05/06/2020
Last Update Date: 10/27/2023
Certification Date: 12/16/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

835 S VAN BUREN ST
GREEN BAY WI
54301-3526
US

IV. Provider business mailing address

4228 DOWNTON CIR
GREEN BAY WI
54313-9110
US

V. Phone/Fax

Practice location:
  • Phone: 417-499-9141
  • Fax:
Mailing address:
  • Phone: 417-499-9141
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number10419-33
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: