Provider Demographics
NPI:1730848201
Name:ROACH, LACEY ELIZABETH (CNP)
Entity type:Individual
Prefix:MISS
First Name:LACEY
Middle Name:ELIZABETH
Last Name:ROACH
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6516 N OLIE AVE STE G
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73116-7399
Mailing Address - Country:US
Mailing Address - Phone:405-608-8060
Mailing Address - Fax:405-608-8070
Practice Address - Street 1:6516 N OLIE AVE STE G
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73116-7399
Practice Address - Country:US
Practice Address - Phone:405-608-8060
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-13
Last Update Date:2024-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKR023091363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily