Provider Demographics
NPI:1487421103
Name:PORTER, LACIE DIANA (ARNP)
Entity type:Individual
Prefix:
First Name:LACIE
Middle Name:DIANA
Last Name:PORTER
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:729 S 10TH AVE
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:IA
Mailing Address - Zip Code:52353-1303
Mailing Address - Country:US
Mailing Address - Phone:172-029-9172
Mailing Address - Fax:
Practice Address - Street 1:400 E POLK ST
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:IA
Practice Address - Zip Code:52353-1237
Practice Address - Country:US
Practice Address - Phone:720-299-1721
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-12-04
Last Update Date:2023-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAA177192363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily