Provider Demographics
NPI:1275973638
Name:WELLER, LACEY M (NP)
Entity Type:Individual
Prefix:
First Name:LACEY
Middle Name:M
Last Name:WELLER
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:LACEY
Other - Middle Name:E
Other - Last Name:MORGAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:711 TROY SCHENECTADY RD STE 203
Mailing Address - Street 2:
Mailing Address - City:LATHAM
Mailing Address - State:NY
Mailing Address - Zip Code:12110-2461
Mailing Address - Country:US
Mailing Address - Phone:518-782-3700
Mailing Address - Fax:518-782-3799
Practice Address - Street 1:286 STAGE RD
Practice Address - Street 2:
Practice Address - City:CHARLTON
Practice Address - State:NY
Practice Address - Zip Code:12019-2618
Practice Address - Country:US
Practice Address - Phone:518-399-2101
Practice Address - Fax:518-399-2130
Is Sole Proprietor?:No
Enumeration Date:2013-07-01
Last Update Date:2018-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY338016363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY130920000077OtherFIDELIS CARE NY
NY03605323Medicaid
NYJ400094164Medicare PIN