Healthcare Provider Details

I. General information

NPI: 1104755446
Provider Name (Legal Business Name): LACEY GEMMELL BSN, RN, AMB-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/14/2026
Last Update Date: 05/14/2026
Certification Date: 05/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

90 PRESIDENTIAL PLZ FL 4
SYRACUSE NY
13202-2240
US

IV. Provider business mailing address

104 E ROSWELL AVE
NEDROW NY
13120-1014
US

V. Phone/Fax

Practice location:
  • Phone: 315-464-3836
  • Fax:
Mailing address:
  • Phone: 315-464-3836
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RR0500X
TaxonomyRheumatology Physician
License Number691586
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: