Basic Information
| Provider Information | |||||||||
| NPI: | 1679834857 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RAICHE | ||||||||
| FirstName: | LACEY | ||||||||
| MiddleName: | JO | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | FNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3603 SCHNEIDER AVENUE | ||||||||
| Address2: | |||||||||
| City: | MENOMONIE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 547515674 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7152336400 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3603 SCHNEIDER AVENUE | ||||||||
| Address2: | |||||||||
| City: | MENOMONIE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 547515674 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7152336400 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/04/2012 | ||||||||
| LastUpdateDate: | 03/31/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 03/31/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | R207746-8 | MN | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363LF0000X | 162013-30 | WI | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 1679834857 | 05 | MN | MEDICAID |