Provider Demographics
NPI:1760832117
Name:MCMILLAN, LACEY (MD)
Entity type:Individual
Prefix:DR
First Name:LACEY
Middle Name:
Last Name:MCMILLAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:LACEY
Other - Middle Name:
Other - Last Name:AVILA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:27617 TIERRA DEL SOL LN
Mailing Address - Street 2:
Mailing Address - City:BONITA SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:34135-3553
Mailing Address - Country:US
Mailing Address - Phone:305-619-1680
Mailing Address - Fax:
Practice Address - Street 1:630 S FLEISHEL AVE
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75701-2041
Practice Address - Country:US
Practice Address - Phone:903-606-5560
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-16
Last Update Date:2025-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLTRN 23830208600000X
MA10175312086S0102X, 2086S0127X
FLME1486592086S0127X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0127XAllopathic & Osteopathic PhysiciansSurgeryTrauma Surgery
No208600000XAllopathic & Osteopathic PhysiciansSurgery
No2086S0102XAllopathic & Osteopathic PhysiciansSurgerySurgical Critical Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLU9993OtherMEDICARE HF
FLU9996OtherMEDICARE HFPS
FL111265500Medicaid