Provider Demographics
NPI:1689088205
Name:LUNDGREN, LACEY (APRN)
Entity type:Individual
Prefix:
First Name:LACEY
Middle Name:
Last Name:LUNDGREN
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16800 LUND RD N
Mailing Address - Street 2:
Mailing Address - City:ELGIN
Mailing Address - State:TX
Mailing Address - Zip Code:78621-3830
Mailing Address - Country:US
Mailing Address - Phone:512-413-5190
Mailing Address - Fax:
Practice Address - Street 1:1128 TX-21
Practice Address - Street 2:
Practice Address - City:BASTROP
Practice Address - State:TX
Practice Address - Zip Code:78602-4298
Practice Address - Country:US
Practice Address - Phone:844-215-4498
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-12
Last Update Date:2024-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP1257772084P0800X, 363LF0000X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX342462401Medicaid
TX791283OtherRN LICENSE
TXAP125777OtherAPRN LICENSE NO.
TX791283OtherRN LICENSE