Healthcare Provider Details

I. General information

NPI: 1851474746
Provider Name (Legal Business Name): ELAINE M LACEY PA C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/23/2006
Last Update Date: 11/28/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

667 S RIVER ST
PLAINS PA
18705
US

IV. Provider business mailing address

667 S RIVER ST
PLAINS PA
18705-1013
US

V. Phone/Fax

Practice location:
  • Phone: 570-824-4111
  • Fax: 570-824-3167
Mailing address:
  • Phone: 570-824-4111
  • Fax: 570-824-3167

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberMA001683L
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: