MEDICARE: LACEY WILLOUGHBY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	171M00000X	Case Manager/Care Coordinator

General Provider Information

NPI Number	:	1194382168
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LACEY WILLOUGHBY

Provider Business Mailing Address
First Line	:	PO BOX 194
Second Line	:
City	:	HAWK SPRINGS
State	:	WY
Zip	:	82217-0194
Country	:	US
Telephone Number	:	307-575-9726
Fax Number	:

Provider Business Practice Location Address
First Line	:	435 MAIN ST
Second Line	:
City	:	HAWK SPRINGS
State	:	WY
Zip	:	82217-5016
Country	:	US
Telephone Number	:	307-575-9726
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/23/2019
Last Update Date	:	05/23/2019

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Directions to “ LACEY WILLOUGHBY ” Practice Location

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