Provider Demographics
NPI:1548799562
Name:NEELEY, LANCE
Entity Type:Individual
Prefix:
First Name:LANCE
Middle Name:
Last Name:NEELEY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1134 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BELLEFONTAINE
Mailing Address - State:OH
Mailing Address - Zip Code:43311-2815
Mailing Address - Country:US
Mailing Address - Phone:937-593-0245
Mailing Address - Fax:
Practice Address - Street 1:1001 W PIKE ST
Practice Address - Street 2:
Practice Address - City:JACKSON CENTER
Practice Address - State:OH
Practice Address - Zip Code:45334-6066
Practice Address - Country:US
Practice Address - Phone:937-421-4081
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-05
Last Update Date:2024-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAPRN.CNP.021905363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0252621Medicaid