Provider Demographics
NPI:1174916480
Name:LACEY, BROOKE A (APRN)
Entity type:Individual
Prefix:
First Name:BROOKE
Middle Name:A
Last Name:LACEY
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:BROOKE
Other - Middle Name:A
Other - Last Name:POWELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:900 S PINE ISLAND RD STE 800
Mailing Address - Street 2:
Mailing Address - City:PLANTATION
Mailing Address - State:FL
Mailing Address - Zip Code:33324-3923
Mailing Address - Country:US
Mailing Address - Phone:386-734-1824
Mailing Address - Fax:386-738-7497
Practice Address - Street 1:809 N STONE ST
Practice Address - Street 2:
Practice Address - City:DELAND
Practice Address - State:FL
Practice Address - Zip Code:32720-3255
Practice Address - Country:US
Practice Address - Phone:386-734-1824
Practice Address - Fax:386-738-7497
Is Sole Proprietor?:No
Enumeration Date:2015-03-11
Last Update Date:2024-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN9233489363L00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL120553400Medicaid