Provider Demographics
NPI:1376984278
Name:BEAVER, LACEY JEAN (RN)
Entity Type:Individual
Prefix:
First Name:LACEY
Middle Name:JEAN
Last Name:BEAVER
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:108 BUCKLEY ST
Mailing Address - Street 2:
Mailing Address - City:LIBERTY
Mailing Address - State:NY
Mailing Address - Zip Code:12754-1602
Mailing Address - Country:US
Mailing Address - Phone:845-701-7537
Mailing Address - Fax:845-342-6582
Practice Address - Street 1:108 BUCKLEY ST
Practice Address - Street 2:
Practice Address - City:LIBERTY
Practice Address - State:NY
Practice Address - Zip Code:12754-1602
Practice Address - Country:US
Practice Address - Phone:845-701-7537
Practice Address - Fax:845-342-6582
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-09
Last Update Date:2013-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY654937-1163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse