Provider Demographics
NPI:1457483513
Name:DANIELS, STACY LYNETTE (LPN)
Entity Type:Individual
Prefix:MRS
First Name:STACY
Middle Name:LYNETTE
Last Name:DANIELS
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 1:2248 HEARTLAND CT
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:45503-1876
Mailing Address - Country:US
Mailing Address - Phone:937-360-2512
Mailing Address - Fax:
Practice Address - Street 1:2248 HEARTLAND CT
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:OH
Practice Address - Zip Code:45503-1876
Practice Address - Country:US
Practice Address - Phone:937-360-2512
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-12
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPN124752164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2700625Medicaid