Provider Demographics
NPI:1407568066
Name:NICKLE, LACIE JO (CNA)
Entity Type:Individual
Prefix:MRS
First Name:LACIE
Middle Name:JO
Last Name:NICKLE
Suffix:
Gender:F
Credentials:CNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:558 N 8TH ST
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:IN
Mailing Address - Zip Code:47842-1851
Mailing Address - Country:US
Mailing Address - Phone:217-499-4981
Mailing Address - Fax:
Practice Address - Street 1:558 N 8TH ST
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:IN
Practice Address - Zip Code:47842-1851
Practice Address - Country:US
Practice Address - Phone:217-499-4981
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-12-14
Last Update Date:2022-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health