Healthcare Provider Details

I. General information

NPI: 1346358082
Provider Name (Legal Business Name): KYLIE M. LACEY N.P.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KYLIE M. FRARY N.P.

II. Dates (important events)

Enumeration Date: 08/25/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

522 S 4TH ST SUITE 500
FULTON NY
13069-2946
US

IV. Provider business mailing address

239 ONEIDA ST
FULTON NY
13069-1228
US

V. Phone/Fax

Practice location:
  • Phone: 315-598-4740
  • Fax: 315-598-4719
Mailing address:
  • Phone: 315-598-4715
  • Fax: 315-598-4733

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberF334695
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: