Healthcare Provider Details

I. General information

NPI: 1174428064
Provider Name (Legal Business Name): LACY FAY OTOOLE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/10/2026
Last Update Date: 10/10/2026
Certification Date: 10/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

950 S OYSTER BAY RD
HICKSVILLE NY
11801-3511
US

IV. Provider business mailing address

426 MANSFIELD AVE
LEVITTOWN NY
11756-5616
US

V. Phone/Fax

Practice location:
  • Phone: 516-390-6544
  • Fax:
Mailing address:
  • Phone: 516-390-6544
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number1114928462
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: