Provider Demographics
NPI:1184227274
Name:KOVACH, STACIE LYNN
Entity Type:Individual
Prefix:
First Name:STACIE
Middle Name:LYNN
Last Name:KOVACH
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 1:7051 CHIPPEWA RD
Mailing Address - Street 2:
Mailing Address - City:MEDINA
Mailing Address - State:OH
Mailing Address - Zip Code:44256-8517
Mailing Address - Country:US
Mailing Address - Phone:330-606-8040
Mailing Address - Fax:
Practice Address - Street 1:7051 CHIPPEWA RD
Practice Address - Street 2:
Practice Address - City:MEDINA
Practice Address - State:OH
Practice Address - Zip Code:44256-8517
Practice Address - Country:US
Practice Address - Phone:330-606-8040
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-19
Last Update Date:2020-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
376J00000X
OH2391979376J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376J00000XNursing Service Related ProvidersHomemaker