Provider Demographics
NPI:1053847509
Name:WATSON, LACI (NP)
Entity Type:Individual
Prefix:
First Name:LACI
Middle Name:
Last Name:WATSON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:475 MURRAY HILL AVE
Mailing Address - Street 2:
Mailing Address - City:TOVEY
Mailing Address - State:IL
Mailing Address - Zip Code:62570-4477
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2239 E COOK ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62703-1944
Practice Address - Country:US
Practice Address - Phone:217-788-2300
Practice Address - Fax:217-788-2343
Is Sole Proprietor?:No
Enumeration Date:2017-05-03
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209.015954363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily