Provider Demographics
NPI:1457027419
Name:SKELTON, LACEY ANN (LEVEL 1 MED AIDE)
Entity Type:Individual
Prefix:
First Name:LACEY
Middle Name:ANN
Last Name:SKELTON
Suffix:
Gender:F
Credentials:LEVEL 1 MED AIDE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18941 CR 305A
Mailing Address - Street 2:
Mailing Address - City:EMINENCE
Mailing Address - State:MO
Mailing Address - Zip Code:65466-6268
Mailing Address - Country:US
Mailing Address - Phone:573-226-5426
Mailing Address - Fax:573-226-5426
Practice Address - Street 1:18941 CR 305A
Practice Address - Street 2:
Practice Address - City:EMINENCE
Practice Address - State:MO
Practice Address - Zip Code:65466-6268
Practice Address - Country:US
Practice Address - Phone:573-226-5426
Practice Address - Fax:573-226-5426
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-19
Last Update Date:2021-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO049124320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO84-1730316Medicaid