Healthcare Provider Details

I. General information

NPI: 1710469986
Provider Name (Legal Business Name): KATIE ANN LACY NURSE PRACTITIONER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/04/2018
Last Update Date: 09/21/2022
Certification Date: 09/21/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6565 PERIMETER DR
DUBLIN OH
43016-8461
US

IV. Provider business mailing address

5 LIMITED PKWY E
REYNOLDSBURG OH
43068-5300
US

V. Phone/Fax

Practice location:
  • Phone: 614-328-9927
  • Fax: 614-389-3727
Mailing address:
  • Phone: 614-577-2279
  • Fax: 614-577-2272

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberF07181075
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License NumberCNP.023491
License Number StateOH
# 3
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRNCNP023491
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: