Provider Demographics
NPI:1588415863
Name:FULCHER, LACEY (NP-C)
Entity type:Individual
Prefix:
First Name:LACEY
Middle Name:
Last Name:FULCHER
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1835 JAMAICA WAY
Mailing Address - Street 2:
Mailing Address - City:VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:92081-7000
Mailing Address - Country:US
Mailing Address - Phone:760-224-6421
Mailing Address - Fax:
Practice Address - Street 1:4510 EXECUTIVE DR STE 103
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92121-3022
Practice Address - Country:US
Practice Address - Phone:858-677-9352
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-27
Last Update Date:2024-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95028425363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty