Basic Information
| Provider Information | |||||||||
| NPI: | 1497221162 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LACY | ||||||||
| FirstName: | COMFORT | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2222 E STATE ST STE 209 | ||||||||
| Address2: | |||||||||
| City: | ROCKFORD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 611041572 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8159888500 | ||||||||
| FaxNumber: | 8159775956 | ||||||||
| Practice Location | |||||||||
| Address1: | 2222 E STATE ST STE 209 | ||||||||
| Address2: | |||||||||
| City: | ROCKFORD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 611041572 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8159888500 | ||||||||
| FaxNumber: | 8159775956 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/19/2018 | ||||||||
| LastUpdateDate: | 03/02/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 03/02/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP2300X | 209018397 | IL | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Primary Care | 363LF0000X | 209018397 | IL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.