Provider Demographics
NPI:1396564894
Name:LONG, LACY
Entity type:Individual
Prefix:
First Name:LACY
Middle Name:
Last Name:LONG
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 1:341208 E HOPE CIR S
Mailing Address - Street 2:
Mailing Address - City:CHANDLER
Mailing Address - State:OK
Mailing Address - Zip Code:74834-6673
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:341208 E HOPE CIR S
Practice Address - Street 2:
Practice Address - City:CHANDLER
Practice Address - State:OK
Practice Address - Zip Code:74834-6673
Practice Address - Country:US
Practice Address - Phone:405-509-4764
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-10
Last Update Date:2024-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKR0110416163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse