Provider Demographics
NPI:1013144021
Name:MOY, LACEY DIVELY (MD)
Entity Type:Individual
Prefix:MRS
First Name:LACEY
Middle Name:DIVELY
Last Name:MOY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:MS
Other - First Name:LACEY
Other - Middle Name:M
Other - Last Name:DIVELY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:3220 ATLANTA ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62707-8801
Mailing Address - Country:US
Mailing Address - Phone:217-588-7400
Mailing Address - Fax:217-588-7439
Practice Address - Street 1:3220 ATLANTA ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62707-8801
Practice Address - Country:US
Practice Address - Phone:217-588-7400
Practice Address - Fax:217-588-7439
Is Sole Proprietor?:No
Enumeration Date:2009-06-17
Last Update Date:2023-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036129248207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036.129248OtherMD LICENSE