Provider Demographics
NPI:1215530522
Name:REILLY, LACI LYNN (APRN)
Entity type:Individual
Prefix:MRS
First Name:LACI
Middle Name:LYNN
Last Name:REILLY
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9732 STATE ROUTE 12
Mailing Address - Street 2:
Mailing Address - City:COPENHAGEN
Mailing Address - State:NY
Mailing Address - Zip Code:13626-2906
Mailing Address - Country:US
Mailing Address - Phone:719-250-1131
Mailing Address - Fax:
Practice Address - Street 1:9732 STATE ROUTE 12
Practice Address - Street 2:
Practice Address - City:COPENHAGEN
Practice Address - State:NY
Practice Address - Zip Code:13626-2906
Practice Address - Country:US
Practice Address - Phone:719-250-1131
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-18
Last Update Date:2023-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY352408363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily