Individual
MRS. LACEY DIVELY MOY
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
MD
Contact information
Practice address
3220 ATLANTA ST, SPRINGFIELD, IL 62707-8801
(217) 588-7400
(217) 588-7439
Mailing address
3220 ATLANTA ST, SPRINGFIELD, IL 62707-8801
(217) 588-7400
(217) 588-7439
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
Primary
036129248
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
036.129248
MD LICENSE
IL
Enumeration date
06/17/2009
Last updated
05/16/2023
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