Provider Demographics
NPI:1790269850
Name:STALEY, DANA LYNN
Entity Type:Individual
Prefix:
First Name:DANA
Middle Name:LYNN
Last Name:STALEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1594 AKRON RD
Mailing Address - Street 2:
Mailing Address - City:WOOSTER
Mailing Address - State:OH
Mailing Address - Zip Code:44691-2586
Mailing Address - Country:US
Mailing Address - Phone:330-749-7936
Mailing Address - Fax:
Practice Address - Street 1:1594 AKRON RD
Practice Address - Street 2:
Practice Address - City:WOOSTER
Practice Address - State:OH
Practice Address - Zip Code:44691-2586
Practice Address - Country:US
Practice Address - Phone:330-749-7936
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-24
Last Update Date:2018-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0304801Medicaid