Provider Demographics
NPI:1790865517
Name:SPROUSE, GREGORY LLOYD (LPN)
Entity Type:Individual
Prefix:MR
First Name:GREGORY
Middle Name:LLOYD
Last Name:SPROUSE
Suffix:
Gender:M
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16 HERBSTER ST
Mailing Address - Street 2:
Mailing Address - City:COLUMBIANA
Mailing Address - State:OH
Mailing Address - Zip Code:44408-1145
Mailing Address - Country:US
Mailing Address - Phone:330-482-0161
Mailing Address - Fax:
Practice Address - Street 1:16 HERBSTER ST
Practice Address - Street 2:
Practice Address - City:COLUMBIANA
Practice Address - State:OH
Practice Address - Zip Code:44408-1145
Practice Address - Country:US
Practice Address - Phone:330-482-0161
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-16
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPN084417164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2290435Medicaid