Healthcare Provider Details

I. General information

NPI: 1285508481
Provider Name (Legal Business Name): CAROLYN RENEE LACY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/01/2025
Last Update Date: 10/01/2025
Certification Date: 10/01/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

42105 W CHEYENNE DR
MARICOPA AZ
85138-3356
US

IV. Provider business mailing address

42105 W CHEYENNE DR
MARICOPA AZ
85138-3356
US

V. Phone/Fax

Practice location:
  • Phone: 602-319-8130
  • Fax: 520-568-2709
Mailing address:
  • Phone: 602-319-8130
  • Fax: 520-568-2709

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number19802903
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code247000000X
TaxonomyHealth Information Technician
License Number19662609
License Number StateAZ
# 3
Primary TaxonomyN
Taxonomy Code372600000X
TaxonomyAdult Companion
License Number19591027
License Number StateAZ
# 4
Primary TaxonomyN
Taxonomy Code3747P1801X
TaxonomyPersonal Care Attendant
License Number19623108
License Number StateAZ
# 5
Primary TaxonomyN
Taxonomy Code374U00000X
TaxonomyHome Health Aide
License Number19572204
License Number StateAZ
# 6
Primary TaxonomyY
Taxonomy Code173000000X
TaxonomyLegal Medicine
License Number19751503
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: