Provider Demographics
NPI:1558701920
Name:LUNDGREN, LACY L (MIDWIFE)
Entity Type:Individual
Prefix:
First Name:LACY
Middle Name:L
Last Name:LUNDGREN
Suffix:
Gender:F
Credentials:MIDWIFE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 N 4TH AVE E STE 200
Mailing Address - Street 2:
Mailing Address - City:NEWTON
Mailing Address - State:IA
Mailing Address - Zip Code:50208-3122
Mailing Address - Country:US
Mailing Address - Phone:641-792-2112
Mailing Address - Fax:641-792-8484
Practice Address - Street 1:300 N 4TH AVE E STE 200
Practice Address - Street 2:
Practice Address - City:NEWTON
Practice Address - State:IA
Practice Address - Zip Code:50208-3122
Practice Address - Country:US
Practice Address - Phone:641-792-2112
Practice Address - Fax:641-792-8484
Is Sole Proprietor?:No
Enumeration Date:2013-07-01
Last Update Date:2015-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAB131737367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife