| Doctor Name: | MRS. LACEY SULLIVAN |
| NPI Number: | 1174951503 |
| Entity Type Code: | Individual (1) |
| Gender: | F |
| Credentials: | FNP-BC |
| License Number: | 2013037701 |
| Business Practice Address: | 101 Kingsbury Blvd Fredericktown, MO - 636457959 |
| Business Phone Number: | 5737837625 |
| Business Fax Number: | 5737835951 |
| Mailing Address: | 101 Kingsbury Blvd, FREDERICKTOWN |
| State: | MO |
| Postal Code: | 636457959 |
| Phone Number: | 5737837625 |
| Fax Number: | 5737835951 |
| NPI Enumeration Date: | 10/22/2013 |
| NPI Last Update Date: | 10/29/2014 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 363LF0000X |
| License Number: | 2013037701 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | MO |
| Taxonomy Type: | Physician Assistants & Advanced Practice Nursing Providers |
| Taxonomy Classification: | Nurse Practitioner |
| Taxonomy Specialization: | Family |
| Taxonomy Definition: | |