Healthcare Provider Details

I. General information

NPI: 1851891071
Provider Name (Legal Business Name): LACEY N MCMAHILL APN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LACEY HAM

II. Dates (important events)

Enumeration Date: 02/14/2018
Last Update Date: 04/08/2021
Certification Date: 04/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

180 S MAIN ST
CANTON IL
61520-2608
US

IV. Provider business mailing address

180 S MAIN ST
CANTON IL
61520-2608
US

V. Phone/Fax

Practice location:
  • Phone: 309-647-0201
  • Fax: 309-649-6800
Mailing address:
  • Phone: 309-647-0201
  • Fax: 309-647-8613

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209.016917
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: