Individual
MISS LACEY LEE WILSON
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Contact information
Practice address
4859 N 20TH ST, PHOENIX, AZ 85016-4707
(602) 669-3850
Mailing address
735 E GARY LN, PHOENIX, AZ 85042-6647
(602) 814-2852
Taxonomy
Speciality
Code
Description
License number
State
363L00000X
Nurse Practitioner
Primary
315636
AZ
Other
Enumeration date
10/16/2024
Last updated
10/16/2024
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