Provider Demographics
NPI:1710223516
Name:LACY, NICOLE (RN)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:LACY
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 1:14426 120TH AVE
Mailing Address - Street 2:
Mailing Address - City:JAMAICA
Mailing Address - State:NY
Mailing Address - Zip Code:11436-1503
Mailing Address - Country:US
Mailing Address - Phone:718-506-8057
Mailing Address - Fax:
Practice Address - Street 1:14426 120TH AVE
Practice Address - Street 2:
Practice Address - City:JAMAICA
Practice Address - State:NY
Practice Address - Zip Code:11436-1503
Practice Address - Country:US
Practice Address - Phone:718-506-8057
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-12-26
Last Update Date:2024-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY343280950612E376K00000X
NY806780163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No376K00000XNursing Service Related ProvidersNurse's Aide