Provider Demographics
NPI:1104646793
Name:WILSON, LACEY LEE
Entity type:Individual
Prefix:MISS
First Name:LACEY
Middle Name:LEE
Last Name:WILSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:735 E GARY LN
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85042-6647
Mailing Address - Country:US
Mailing Address - Phone:602-814-2852
Mailing Address - Fax:
Practice Address - Street 1:4859 N 20TH ST
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85016-4707
Practice Address - Country:US
Practice Address - Phone:602-669-3850
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-16
Last Update Date:2024-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ315636363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner