Provider Demographics
NPI:1114252087
Name:CARLS, LACEY MARIE (PA-C)
Entity Type:Individual
Prefix:MISS
First Name:LACEY
Middle Name:MARIE
Last Name:CARLS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:725 SCHOOL ST STE A
Mailing Address - Street 2:
Mailing Address - City:MORRIS
Mailing Address - State:IL
Mailing Address - Zip Code:60450-1207
Mailing Address - Country:US
Mailing Address - Phone:815-705-1405
Mailing Address - Fax:
Practice Address - Street 1:1306 GEMINI CIR STE 2
Practice Address - Street 2:
Practice Address - City:OTTAWA
Practice Address - State:IL
Practice Address - Zip Code:61350
Practice Address - Country:US
Practice Address - Phone:815-433-0850
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-10-12
Last Update Date:2023-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085003635363AS0400X
IL085.003635363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical