Healthcare Provider Details

I. General information

NPI: 1689145211
Provider Name (Legal Business Name): LACY GEORGETTE IRELAND FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LACY GEORGETTE LAWSON RN

II. Dates (important events)

Enumeration Date: 12/07/2018
Last Update Date: 12/07/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 N BROADWAY
PERU IN
46970-1070
US

IV. Provider business mailing address

1000 N BROADWAY
PERU IN
46970-1070
US

V. Phone/Fax

Practice location:
  • Phone: 765-472-5335
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number28188363A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: