Provider Demographics
NPI:1376117028
Name:ODOM-LACY, YVETTE
Entity Type:Individual
Prefix:
First Name:YVETTE
Middle Name:
Last Name:ODOM-LACY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1445 KEMBLE ST
Mailing Address - Street 2:
Mailing Address - City:UTICA
Mailing Address - State:NY
Mailing Address - Zip Code:13501-4441
Mailing Address - Country:US
Mailing Address - Phone:315-732-0100
Mailing Address - Fax:
Practice Address - Street 1:1445 KEMBLE ST
Practice Address - Street 2:
Practice Address - City:UTICA
Practice Address - State:NY
Practice Address - Zip Code:13501-4441
Practice Address - Country:US
Practice Address - Phone:315-732-0100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-18
Last Update Date:2021-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY578782163WG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WG0600XNursing Service ProvidersRegistered NurseGerontology