Provider Demographics
NPI:1659868644
Name:ELLYSON, LACEY (NP-C)
Entity Type:Individual
Prefix:
First Name:LACEY
Middle Name:
Last Name:ELLYSON
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:LACEY
Other - Middle Name:
Other - Last Name:GLOVER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:1 PERKINS SQ
Mailing Address - Street 2:
Mailing Address - City:AKRON
Mailing Address - State:OH
Mailing Address - Zip Code:44308-1063
Mailing Address - Country:US
Mailing Address - Phone:330-424-9866
Mailing Address - Fax:
Practice Address - Street 1:400 N MARKET ST
Practice Address - Street 2:
Practice Address - City:LISBON
Practice Address - State:OH
Practice Address - Zip Code:44432-1146
Practice Address - Country:US
Practice Address - Phone:330-424-9866
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-16
Last Update Date:2021-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAPRN.CNP.022504363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily