Provider Demographics
NPI:1871810580
Name:MILLER, LACY M (RN)
Entity type:Individual
Prefix:
First Name:LACY
Middle Name:M
Last Name:MILLER
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1874 LAKESHORE DR.
Mailing Address - Street 2:P.O. BOX 743
Mailing Address - City:SELMA
Mailing Address - State:OR
Mailing Address - Zip Code:97538
Mailing Address - Country:US
Mailing Address - Phone:541-597-2103
Mailing Address - Fax:
Practice Address - Street 1:1874 LAKESHORE DR.
Practice Address - Street 2:
Practice Address - City:SELMA
Practice Address - State:OR
Practice Address - Zip Code:97538
Practice Address - Country:US
Practice Address - Phone:541-597-2103
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-04-21
Last Update Date:2010-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR200340992RN163WC1500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC1500XNursing Service ProvidersRegistered NurseCommunity Health