Healthcare Provider Details

I. General information

NPI: 1588258529
Provider Name (Legal Business Name): LACY JO HARGITT-PELKEY APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/20/2021
Last Update Date: 07/19/2024
Certification Date: 07/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4 COMMERCE LN
CANTON NY
13617-3739
US

IV. Provider business mailing address

4 COMMERCE LN
CANTON NY
13617-3739
US

V. Phone/Fax

Practice location:
  • Phone: 315-386-8191
  • Fax:
Mailing address:
  • Phone: 315-386-8191
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number626129
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number105992
License Number StateKS
# 3
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number53-79418-032
License Number StateKS
# 4
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberF353110
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: