Basic Information
| Provider Information | |||||||||
| NPI: | 1568199867 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FELTEN | ||||||||
| FirstName: | LACEY | ||||||||
| MiddleName: | ANNE | ||||||||
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| Credential: | ACNPC-AG | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | DELORE | ||||||||
| OtherFirstName: | LACEY | ||||||||
| OtherMiddleName: | ANNE | ||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 430 N 2ND ST | ||||||||
| Address2: | |||||||||
| City: | FREELAND | ||||||||
| State: | MI | ||||||||
| PostalCode: | 486232505 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9894508857 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2660 W SUGNET RD | ||||||||
| Address2: | |||||||||
| City: | MIDLAND | ||||||||
| State: | MI | ||||||||
| PostalCode: | 486704860 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9898320900 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/05/2022 | ||||||||
| LastUpdateDate: | 11/10/2022 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 11/10/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2100X | 4704322011NSA220KV | MI | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Acute Care |
No ID Information.