Provider Demographics
NPI:1679303119
Name:WILSON, LACEY-ANN ALICIA
Entity type:Individual
Prefix:
First Name:LACEY-ANN
Middle Name:ALICIA
Last Name:WILSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1406 NEW YORK AVE APT 6F
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11210-1631
Mailing Address - Country:US
Mailing Address - Phone:347-533-9491
Mailing Address - Fax:
Practice Address - Street 1:1358 56TH ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11219-4616
Practice Address - Country:US
Practice Address - Phone:718-854-0048
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-07
Last Update Date:2025-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY915552163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse