Healthcare Provider Details

I. General information

NPI: 1164736526
Provider Name (Legal Business Name): CHRISTINA LYNN SOBCZAK PNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: CHRISTINA LYNN LACKEMEYER

II. Dates (important events)

Enumeration Date: 07/28/2010
Last Update Date: 08/12/2024
Certification Date: 08/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

860 MAIN ROAD
CORFU NY
14036-9753
US

IV. Provider business mailing address

860 MAIN RD
CORFU NY
14036-9753
US

V. Phone/Fax

Practice location:
  • Phone: 585-599-6446
  • Fax: 585-599-6446
Mailing address:
  • Phone: 585-599-6446
  • Fax: 585-599-3166

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number543559-1
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number382152
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: