Basic Information
| Provider Information | |||||||||
| NPI: | 1104366228 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | VANEMBURG | ||||||||
| FirstName: | LACEY | ||||||||
| MiddleName: | R | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | CRNA | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | GAMMILL | ||||||||
| OtherFirstName: | LACEY | ||||||||
| OtherMiddleName: | R | ||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 9007 | ||||||||
| Address2: | |||||||||
| City: | SPRINGFIELD | ||||||||
| State: | MO | ||||||||
| PostalCode: | 658089007 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4178753000 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 525 BRANSON LANDING BLVD | ||||||||
| Address2: | |||||||||
| City: | BRANSON | ||||||||
| State: | MO | ||||||||
| PostalCode: | 656162052 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4172393392 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/08/2017 | ||||||||
| LastUpdateDate: | 12/14/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 12/14/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | R085616 | AR | N | Nursing Service Providers | Registered Nurse | 367500000X | CO03204 | AR | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 910051138 | 05 | MO | MEDICAID |