Provider Demographics
NPI:1174951503
Name:SULLIVAN, LACEY (FNP-BC)
Entity type:Individual
Prefix:MRS
First Name:LACEY
Middle Name:
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:608 MAPLE VALLEY DR
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:MO
Mailing Address - Zip Code:63640-1976
Mailing Address - Country:US
Mailing Address - Phone:573-756-3400
Mailing Address - Fax:573-756-0800
Practice Address - Street 1:618 MAPLE VALLEY DR
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:MO
Practice Address - Zip Code:63640
Practice Address - Country:US
Practice Address - Phone:573-756-3400
Practice Address - Fax:573-756-0800
Is Sole Proprietor?:No
Enumeration Date:2013-10-22
Last Update Date:2022-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2013037701363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO2013037701OtherFNP LICENSE
MO2008021920OtherRN LICENSE
MO2013017822OtherANCC