Provider Demographics
NPI:1427580968
Name:INDIVIDUAL PRACTITIONER
Entity Type:Organization
Organization Name:INDIVIDUAL PRACTITIONER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LPN
Authorized Official - Prefix:MS
Authorized Official - First Name:LU
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:MCCLOY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:740-652-4645
Mailing Address - Street 1:1496 TARKILN RD SE
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:OH
Mailing Address - Zip Code:43130-9006
Mailing Address - Country:US
Mailing Address - Phone:740-415-3667
Mailing Address - Fax:
Practice Address - Street 1:1496 TARKILN RD SE
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:OH
Practice Address - Zip Code:43130-9006
Practice Address - Country:US
Practice Address - Phone:740-415-3667
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-04-03
Last Update Date:2017-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH149852251J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251J00000XAgenciesNursing Care