Provider Demographics
NPI:1336961697
Name:TUPPER, LACIE
Entity type:Individual
Prefix:
First Name:LACIE
Middle Name:
Last Name:TUPPER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:LACE
Other - Middle Name:
Other - Last Name:TUPPER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1900 BEAN CREEK RD
Mailing Address - Street 2:
Mailing Address - City:SCOTTS VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:95066-3322
Mailing Address - Country:US
Mailing Address - Phone:603-660-7049
Mailing Address - Fax:
Practice Address - Street 1:1900 BEAN CREEK RD
Practice Address - Street 2:
Practice Address - City:SCOTTS VALLEY
Practice Address - State:CA
Practice Address - Zip Code:95066-3322
Practice Address - Country:US
Practice Address - Phone:603-660-7049
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-28
Last Update Date:2024-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA374J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes374J00000XNursing Service Related ProvidersDoulaGroup - Single Specialty