Individual
MICHELLE MACEY THACKER
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
NP-C
Contact information
Practice address
2111 LEXINGTON AVE, LAWRENCEVILLE, IL 62439
(618) 943-7214
Mailing address
2111 LEXINGTON AVE, LAWRENCEVILLE, IL 62439
Taxonomy
Speciality
Code
Description
License number
State
363L00000X
Nurse Practitioner
Primary
71010904A
IN
363LF0000X
Family Nurse Practitioner
209017621
IL
Other
Enumeration date
05/10/2018
Last updated
04/20/2023
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