Provider Demographics
NPI:1760622914
Name:POWELL, LACI JADE (STNA)
Entity Type:Individual
Prefix:MISS
First Name:LACI
Middle Name:JADE
Last Name:POWELL
Suffix:
Gender:F
Credentials:STNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4458 W POPLAR RIDGE RD NW
Mailing Address - Street 2:
Mailing Address - City:MALTA
Mailing Address - State:OH
Mailing Address - Zip Code:43758-9127
Mailing Address - Country:US
Mailing Address - Phone:740-962-6169
Mailing Address - Fax:
Practice Address - Street 1:4458 W POPLAR RIDGE RD NW
Practice Address - Street 2:
Practice Address - City:MALTA
Practice Address - State:OH
Practice Address - Zip Code:43758-9127
Practice Address - Country:US
Practice Address - Phone:740-962-6169
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-03-01
Last Update Date:2009-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH400767990608376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide