Healthcare Provider Details

I. General information

NPI: 1659861789
Provider Name (Legal Business Name): LACEY ANGLE COLLINS RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/15/2018
Last Update Date: 10/02/2024
Certification Date: 10/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

83 ORCHARD DRIVE
LEEDS NY
12451
US

IV. Provider business mailing address

18 PULVER AVE
RAVENA NY
12143-1323
US

V. Phone/Fax

Practice location:
  • Phone: 518-821-5380
  • Fax:
Mailing address:
  • Phone: 518-821-5380
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number739290
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: