Healthcare Provider Details

I. General information

NPI: 1295662393
Provider Name (Legal Business Name): COURTNEY ERIN LACY PA-S
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/05/2026
Last Update Date: 08/28/2026
Certification Date: 08/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9981 S HEALTHPARK DR
FORT MYERS FL
33908-3618
US

IV. Provider business mailing address

PO BOX 2147
FORT MYERS FL
33902-2147
US

V. Phone/Fax

Practice location:
  • Phone: 239-342-5000
  • Fax:
Mailing address:
  • Phone: 239-343-2052
  • Fax: 239-343-1009

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA9122032
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: