Healthcare Provider Details

I. General information

NPI: 1124917372
Provider Name (Legal Business Name): DANIEL LACY RN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/01/2025
Last Update Date: 07/01/2025
Certification Date: 07/01/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2131 S 17TH ST
WILMINGTON NC
28401-7407
US

IV. Provider business mailing address

409 TRIBUTARY CIR
WILMINGTON NC
28401-7051
US

V. Phone/Fax

Practice location:
  • Phone: 910-667-7000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC0200X
TaxonomyCritical Care Medicine Registered Nurse
License Number327553
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: