Provider Demographics
NPI:1467905471
Name:ROBERTSON, LACY (RN, IBCLC)
Entity type:Individual
Prefix:
First Name:LACY
Middle Name:
Last Name:ROBERTSON
Suffix:
Gender:F
Credentials:RN, IBCLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23740 CHAMPION DR
Mailing Address - Street 2:
Mailing Address - City:LINDALE
Mailing Address - State:TX
Mailing Address - Zip Code:75771-5554
Mailing Address - Country:US
Mailing Address - Phone:903-714-5864
Mailing Address - Fax:
Practice Address - Street 1:112 MAVERICK CT
Practice Address - Street 2:
Practice Address - City:GRANBURY
Practice Address - State:TX
Practice Address - Zip Code:76049-1381
Practice Address - Country:US
Practice Address - Phone:888-731-8994
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-26
Last Update Date:2025-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL-87846163WL0100X
TXAP145224363LF0000X
TX809899163WL0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163WL0100XNursing Service ProvidersRegistered NurseLactation Consultant