MEDICARE: LACEY BRIDGET MAUDE CRNP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	SP032287	PA
2	163W00000X	Registered Nurse	RN631213	PA

General Provider Information

NPI Number	:	1083410666
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LACEY BRIDGET MAUDE CRNP

Provider Business Mailing Address
First Line	:	100 SHENANGO AVE
Second Line	:
City	:	SHARON
State	:	PA
Zip	:	16146-1503
Country	:	US
Telephone Number	:	724-658-4564
Fax Number	:	724-657-8563

Provider Business Practice Location Address
First Line	:	26 NESBITT RD STE 253
Second Line	:
City	:	NEW CASTLE
State	:	PA
Zip	:	16105-3414
Country	:	US
Telephone Number	:	724-652-2323
Fax Number	:	724-654-3461

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/24/2025
Last Update Date	:	03/06/2026

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