Provider Demographics
NPI:1205379468
Name:KILLIAN, LACIE (CNA)
Entity Type:Individual
Prefix:
First Name:LACIE
Middle Name:
Last Name:KILLIAN
Suffix:
Gender:F
Credentials:CNA
Other - Prefix:
Other - First Name:LACIE
Other - Middle Name:
Other - Last Name:RECTOR
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:CNA
Mailing Address - Street 1:1700 AVENUE G
Mailing Address - Street 2:
Mailing Address - City:DODGE CITY
Mailing Address - State:KS
Mailing Address - Zip Code:67801-4544
Mailing Address - Country:US
Mailing Address - Phone:620-255-8006
Mailing Address - Fax:620-371-7304
Practice Address - Street 1:1700 AVENUE G
Practice Address - Street 2:
Practice Address - City:DODGE CITY
Practice Address - State:KS
Practice Address - Zip Code:67801-4544
Practice Address - Country:US
Practice Address - Phone:620-255-8006
Practice Address - Fax:620-371-7304
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-21
Last Update Date:2016-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS180788222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist