Provider Demographics
NPI:1063248326
Name:LILES, LACEY (MSN, APRN, FNP-BC)
Entity type:Individual
Prefix:
First Name:LACEY
Middle Name:
Last Name:LILES
Suffix:
Gender:F
Credentials:MSN, APRN, FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17 BURNETT AVE
Mailing Address - Street 2:
Mailing Address - City:MAYS LANDING
Mailing Address - State:NJ
Mailing Address - Zip Code:08330-4212
Mailing Address - Country:US
Mailing Address - Phone:727-460-7746
Mailing Address - Fax:
Practice Address - Street 1:75 W RED BANK AVE
Practice Address - Street 2:
Practice Address - City:WOODBURY
Practice Address - State:NJ
Practice Address - Zip Code:08096-1694
Practice Address - Country:US
Practice Address - Phone:856-451-4700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-12
Last Update Date:2024-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NJ15145700363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily