MEDICARE: LACEY BERNICE IVES APRN-CNP

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	363L00000X	Nurse Practitioner	201078	OK
2	363LF0000X	Family Nurse Practitioner	201078	OK
3	363LC0200X	Critical Care Medicine Nurse Practitioner	201078	OK

General Provider Information

NPI Number	:	1255165650
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LACEY BERNICE IVES APRN-CNP

Provider Business Mailing Address
First Line	:	14000 HUNTER JACKSON DR
Second Line	:
City	:	YUKON
State	:	OK
Zip	:	73099-1018
Country	:	US
Telephone Number	:	405-464-8515
Fax Number	:

Provider Business Practice Location Address
First Line	:	3300 NW EXPRESSWAY
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73112-4418
Country	:	US
Telephone Number	:	405-949-3011
Fax Number	:

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

Provider Enumeration Date	:	08/28/2024
Last Update Date	:	03/09/2026

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