Provider Demographics
NPI:1255996104
Name:LACY, AMANDA RENE (FNP)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:RENE
Last Name:LACY
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1007 PAGODA DR
Mailing Address - Street 2:
Mailing Address - City:AMARILLO
Mailing Address - State:TX
Mailing Address - Zip Code:79110-2637
Mailing Address - Country:US
Mailing Address - Phone:806-206-5115
Mailing Address - Fax:
Practice Address - Street 1:1901 MEDI PARK DR STE 1068
Practice Address - Street 2:
Practice Address - City:AMARILLO
Practice Address - State:TX
Practice Address - Zip Code:79106-2108
Practice Address - Country:US
Practice Address - Phone:806-576-1095
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-07
Last Update Date:2019-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX756225363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily