Provider Demographics
NPI:1356470967
Name:THOMAS, STACY S (LPN)
Entity Type:Individual
Prefix:MRS
First Name:STACY
Middle Name:S
Last Name:THOMAS
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 1:3612 PLYMOUTH SPRINGMILL RD
Mailing Address - Street 2:
Mailing Address - City:SHELBY
Mailing Address - State:OH
Mailing Address - Zip Code:44875-9527
Mailing Address - Country:US
Mailing Address - Phone:419-347-2810
Mailing Address - Fax:
Practice Address - Street 1:3612 PLYMOUTH SPRINGMILL RD
Practice Address - Street 2:
Practice Address - City:SHELBY
Practice Address - State:OH
Practice Address - Zip Code:44875-9527
Practice Address - Country:US
Practice Address - Phone:419-347-2810
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPN095965164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHPN095965OtherLPN
OH2575486Medicaid