Provider Demographics
NPI:1902137557
Name:KECK-HEATH, STACEY LYNN (LPN)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:LYNN
Last Name:KECK-HEATH
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:STACEY
Other - Middle Name:L
Other - Last Name:KECK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPN
Mailing Address - Street 1:401 PROSPECT HILL RD
Mailing Address - Street 2:
Mailing Address - City:HORSEHEADS
Mailing Address - State:NY
Mailing Address - Zip Code:14845-8567
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:221 W CHURCH ST
Practice Address - Street 2:
Practice Address - City:ELMIRA
Practice Address - State:NY
Practice Address - Zip Code:14901-2721
Practice Address - Country:US
Practice Address - Phone:607-734-3646
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-01-21
Last Update Date:2010-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY261842-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse