Healthcare Provider Details

I. General information

NPI: 1538683636
Provider Name (Legal Business Name): LACY LEE RAE HOSAY FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/31/2017
Last Update Date: 05/24/2021
Certification Date: 05/24/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1153 E GANNON DR
FESTUS MO
63028-2611
US

IV. Provider business mailing address

1153 E GANNON DR
FESTUS MO
63028-2611
US

V. Phone/Fax

Practice location:
  • Phone: 636-282-0380
  • Fax: 877-592-0806
Mailing address:
  • Phone: 636-282-0380
  • Fax: 877-592-0806

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number2017025491
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: