Individual
LACEY M WELLER
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
NP
Contact information
Practice address
286 STAGE RD, CHARLTON, NY 12019-2618
(518) 399-2101
(518) 399-2130
Mailing address
711 TROY SCHENECTADY RD STE 203, LATHAM, NY 12110-2461
(518) 782-3700
(518) 782-3799
Taxonomy
Speciality
Code
Description
License number
State
363L00000X
Nurse Practitioner
Primary
338016
NY
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
03605323
—
NY
01
—
130920000077
FIDELIS CARE NY
NY
Enumeration date
07/01/2013
Last updated
05/02/2018
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