Provider Demographics
NPI:1164751210
Name:KOON, LUCIA
Entity Type:Individual
Prefix:MISS
First Name:LUCIA
Middle Name:
Last Name:KOON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:191 ROWLAND AVE
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:44903-1444
Mailing Address - Country:US
Mailing Address - Phone:567-303-9587
Mailing Address - Fax:
Practice Address - Street 1:191 ROWLAND AVE
Practice Address - Street 2:
Practice Address - City:MANSFIELD
Practice Address - State:OH
Practice Address - Zip Code:44903-1444
Practice Address - Country:US
Practice Address - Phone:567-303-9587
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-12-21
Last Update Date:2009-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH72546356171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2907724Medicaid
OH2958876Medicaid