Basic Information
| Provider Information | |||||||||
| NPI: | 1346977816 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WILLIAMS | ||||||||
| FirstName: | LACEY | ||||||||
| MiddleName: | REBEKAH | ||||||||
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| Mailing Information | |||||||||
| Address1: | 100 KIMEL FOREST DR | ||||||||
| Address2: | |||||||||
| City: | WINSTON SALEM | ||||||||
| State: | NC | ||||||||
| PostalCode: | 271036074 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3367161331 | ||||||||
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| Practice Location | |||||||||
| Address1: | 136 S PARK ST | ||||||||
| Address2: | |||||||||
| City: | ASHEBORO | ||||||||
| State: | NC | ||||||||
| PostalCode: | 272035651 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3366266371 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/04/2022 | ||||||||
| LastUpdateDate: | 08/16/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/16/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 5016655 | NC | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363L00000X | 5016655 | NC | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.