Healthcare Provider Details

I. General information

NPI: 1679603666
Provider Name (Legal Business Name): BARBARA JO LACY R.N.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/07/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 W OLD LINDEN RD
SHOW LOW AZ
85901-4608
US

IV. Provider business mailing address

500 W OLD LINDEN RD
SHOW LOW AZ
85901-4608
US

V. Phone/Fax

Practice location:
  • Phone: 928-537-6057
  • Fax: 928-537-6099
Mailing address:
  • Phone: 928-537-6057
  • Fax: 928-537-6099

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN060703
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: