Provider Demographics
NPI:1154379949
Name:LACY, MARY ALICE (MSN,FNP)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:ALICE
Last Name:LACY
Suffix:
Gender:F
Credentials:MSN,FNP
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Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:VA SAN DIEGO HEALTHCARE SYSTEM
Mailing Address - Street 2:3350 LA JOLLA VILLAGE DRIVE, MC-118
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92161-0001
Mailing Address - Country:US
Mailing Address - Phone:858-642-1085
Mailing Address - Fax:858-552-4365
Practice Address - Street 1:VA SAN DIEGO HEALTHCARE SYSTEM
Practice Address - Street 2:3350 LA JOLLA VILLAGE DRIVE, MC-118
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92161-0001
Practice Address - Country:US
Practice Address - Phone:858-642-1085
Practice Address - Fax:858-552-4365
Is Sole Proprietor?:No
Enumeration Date:2006-05-04
Last Update Date:2007-07-12
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CA386793363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily