Healthcare Provider Details

I. General information

NPI: 1952218760
Provider Name (Legal Business Name): LACY RUSSELL WHNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LACY GARCIA

II. Dates (important events)

Enumeration Date: 08/26/2026
Last Update Date: 08/26/2026
Certification Date: 08/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

622 W MAPLE ST STE F
FARMINGTON NM
87401-6589
US

IV. Provider business mailing address

622 W MAPLE ST STE F
FARMINGTON NM
87401-6589
US

V. Phone/Fax

Practice location:
  • Phone: 505-326-4700
  • Fax:
Mailing address:
  • Phone: 505-419-0050
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License Number61087
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: