Provider Demographics
NPI:1992358378
Name:SMITH, LACY (FNP-BC, PMHNP-BC)
Entity type:Individual
Prefix:MS
First Name:LACY
Middle Name:
Last Name:SMITH
Suffix:
Gender:
Credentials:FNP-BC, PMHNP-BC
Other - Prefix:MISS
Other - First Name:LACY
Other - Middle Name:
Other - Last Name:MCINTYRE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2524 N BROADWAY STE 554
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73034-4199
Mailing Address - Country:US
Mailing Address - Phone:620-649-2505
Mailing Address - Fax:669-204-0329
Practice Address - Street 1:1031 N KANSAS AVE
Practice Address - Street 2:
Practice Address - City:LIBERAL
Practice Address - State:KS
Practice Address - Zip Code:67901-2644
Practice Address - Country:US
Practice Address - Phone:620-649-2505
Practice Address - Fax:669-204-0329
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-24
Last Update Date:2025-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS13-127040-052163WM0705X
OK216289363LF0000X, 363LP0808X
KS53-78893363LF0000X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163WM0705XNursing Service ProvidersRegistered NurseMedical-Surgical
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS201291660AMedicaid
OK201236440AMedicaid