Provider Demographics
NPI:1518171685
Name:LASLEY, VIVIAN ELESA (IECE SP NEEDS ED)
Entity Type:Individual
Prefix:MRS
First Name:VIVIAN
Middle Name:ELESA
Last Name:LASLEY
Suffix:
Gender:F
Credentials:IECE SP NEEDS ED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 1035
Mailing Address - Street 2:
Mailing Address - City:PINEVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40977
Mailing Address - Country:US
Mailing Address - Phone:606-337-6107
Mailing Address - Fax:606-248-6679
Practice Address - Street 1:HWY 190 W
Practice Address - Street 2:REECE SUBDIVISION
Practice Address - City:PINEVILLE
Practice Address - State:KY
Practice Address - Zip Code:40977
Practice Address - Country:US
Practice Address - Phone:606-337-6107
Practice Address - Fax:606-248-6679
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-09
Last Update Date:2007-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY02015OtherPROVIDER ID NUMBER