Provider Demographics
NPI:1871105916
Name:THEIS, LACIE MICHELLE (ARNP, PMHNP-BC)
Entity type:Individual
Prefix:
First Name:LACIE
Middle Name:MICHELLE
Last Name:THEIS
Suffix:
Gender:F
Credentials:ARNP, PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:814 EASTON AVE
Mailing Address - Street 2:
Mailing Address - City:WATERLOO
Mailing Address - State:IA
Mailing Address - Zip Code:50702-3916
Mailing Address - Country:US
Mailing Address - Phone:319-961-0696
Mailing Address - Fax:
Practice Address - Street 1:111 10TH ST SW
Practice Address - Street 2:
Practice Address - City:WAVERLY
Practice Address - State:IA
Practice Address - Zip Code:50677-2925
Practice Address - Country:US
Practice Address - Phone:319-352-2329
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-19
Last Update Date:2020-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAG159694363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health