Provider Demographics
NPI:1912629601
Name:BRANTNER, LACEY (ARNP)
Entity type:Individual
Prefix:
First Name:LACEY
Middle Name:
Last Name:BRANTNER
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 1:17125 140TH AVE E
Mailing Address - Street 2:
Mailing Address - City:PUYALLUP
Mailing Address - State:WA
Mailing Address - Zip Code:98374-9151
Mailing Address - Country:US
Mailing Address - Phone:253-579-4532
Mailing Address - Fax:
Practice Address - Street 1:11102 SUNRISE BLVD E STE 104
Practice Address - Street 2:
Practice Address - City:PUYALLUP
Practice Address - State:WA
Practice Address - Zip Code:98374-8846
Practice Address - Country:US
Practice Address - Phone:253-848-8797
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-19
Last Update Date:2022-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP61358655363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics