| Doctor Name: | LACEY KAY WILSON |
| NPI Number: | 1720455660 |
| Entity Type Code: | Individual (1) |
| Gender: | F |
| Credentials: | FNP |
| License Number: | 201506113NP-PP |
| Business Practice Address: | 64198 Grays Corner Rd Cove, OR - 978248504 |
| Business Phone Number: | 5418055050 |
| Business Fax Number: | |
| Mailing Address: | 64198 Grays Corner Rd, COVE |
| State: | OR |
| Postal Code: | 978248504 |
| Phone Number: | 5418055050 |
| Fax Number: | |
| NPI Enumeration Date: | 08/26/2015 |
| NPI Last Update Date: | 08/26/2015 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 261QR1300X |
| License Number: | 201506113NP-PP |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | OR |
| Taxonomy Type: | Ambulatory Health Care Facilities |
| Taxonomy Classification: | Clinic/Center |
| Taxonomy Specialization: | Rural Health |
| Taxonomy Definition: | |