Provider Demographics
NPI:1023401015
Name:KING, LORETTA (LPN)
Entity Type:Individual
Prefix:
First Name:LORETTA
Middle Name:
Last Name:KING
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3115 25TH ST SE
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44707-2021
Mailing Address - Country:US
Mailing Address - Phone:330-705-5114
Mailing Address - Fax:
Practice Address - Street 1:3115 25TH ST SE
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:OH
Practice Address - Zip Code:44707-2021
Practice Address - Country:US
Practice Address - Phone:330-705-5114
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-14
Last Update Date:2015-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH107053164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse