Provider Demographics
NPI:1689145211
Name:IRELAND, LACY GEORGETTE (FNP)
Entity Type:Individual
Prefix:
First Name:LACY
Middle Name:GEORGETTE
Last Name:IRELAND
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:LACY
Other - Middle Name:GEORGETTE
Other - Last Name:LAWSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:1000 N BROADWAY
Mailing Address - Street 2:
Mailing Address - City:PERU
Mailing Address - State:IN
Mailing Address - Zip Code:46970-1070
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1000 N BROADWAY
Practice Address - Street 2:
Practice Address - City:PERU
Practice Address - State:IN
Practice Address - Zip Code:46970-1070
Practice Address - Country:US
Practice Address - Phone:765-472-5335
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-07
Last Update Date:2018-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28188363A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily