MEDICARE: LACY GARTH PMHNP-BC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	306071	AZ

General Provider Information

NPI Number	:	1063266658
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LACY GARTH PMHNP-BC

Provider Business Mailing Address
First Line	:	2601 N 3RD ST STE 205
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85004-1145
Country	:	US
Telephone Number	:	480-494-3164
Fax Number	:

Provider Business Practice Location Address
First Line	:	2601 N 3RD ST STE 205
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85004-1145
Country	:	US
Telephone Number	:	480-494-3164
Fax Number	:	602-354-9301

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/11/2024
Last Update Date	:	09/25/2024

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