Provider Demographics
NPI:1669093175
Name:ANDERSON, LACEY RENEE (CRNA)
Entity type:Individual
Prefix:
First Name:LACEY
Middle Name:RENEE
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:LACEY
Other - Middle Name:RENEE
Other - Last Name:GROFF
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4228 DOWNTON CIR
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54313-9110
Mailing Address - Country:US
Mailing Address - Phone:417-499-9141
Mailing Address - Fax:
Practice Address - Street 1:835 S VAN BUREN ST
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54301-3526
Practice Address - Country:US
Practice Address - Phone:417-499-9141
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-06
Last Update Date:2023-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
WI10419-33367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program