Provider Demographics
NPI:1063827780
Name:KEASAL, LEE (NP-C)
Entity Type:Individual
Prefix:MR
First Name:LEE
Middle Name:
Last Name:KEASAL
Suffix:
Gender:M
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:335 GLESSNER AVE RM 325
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:44903-2269
Mailing Address - Country:US
Mailing Address - Phone:419-520-2495
Mailing Address - Fax:
Practice Address - Street 1:2014 BALTIMORE REYNOLDSBURG RD
Practice Address - Street 2:
Practice Address - City:REYNOLDSBURG
Practice Address - State:OH
Practice Address - Zip Code:43068-3261
Practice Address - Country:US
Practice Address - Phone:614-522-6900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-23
Last Update Date:2021-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCOA.15993-NP364SF0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SF0001XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistFamily Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0174849Medicaid