Healthcare Provider Details

I. General information

NPI: 1023840725
Provider Name (Legal Business Name): LACEY MANIMALA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/20/2024
Last Update Date: 09/12/2024
Certification Date: 09/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1026 GUNDERSON AVE
OAK PARK IL
60304-2118
US

IV. Provider business mailing address

1026 GUNDERSON AVE
OAK PARK IL
60304-2118
US

V. Phone/Fax

Practice location:
  • Phone: 312-509-1616
  • Fax:
Mailing address:
  • Phone: 312-509-1616
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367A00000X
TaxonomyAdvanced Practice Midwife
License Number209030375
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code163WX0002X
TaxonomyHigh-Risk Obstetric Registered Nurse
License Number041.447143
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: