Provider Demographics
NPI:1518373083
Name:KILEY, STACY (LPN)
Entity Type:Individual
Prefix:MRS
First Name:STACY
Middle Name:
Last Name:KILEY
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 1:13494 N BOONE RD
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA STATION
Mailing Address - State:OH
Mailing Address - Zip Code:44028-9632
Mailing Address - Country:US
Mailing Address - Phone:440-476-8099
Mailing Address - Fax:
Practice Address - Street 1:13494 N BOONE RD
Practice Address - Street 2:
Practice Address - City:COLUMBIA STATION
Practice Address - State:OH
Practice Address - Zip Code:44028-9632
Practice Address - Country:US
Practice Address - Phone:440-476-8099
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-06
Last Update Date:2014-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPN-151388-M-IV164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse