Provider Demographics
NPI:1821332230
Name:MICCO, EMMA LEE
Entity Type:Individual
Prefix:
First Name:EMMA
Middle Name:LEE
Last Name:MICCO
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 1:447 1/2 S LISBON ST
Mailing Address - Street 2:
Mailing Address - City:CARROLLTON
Mailing Address - State:OH
Mailing Address - Zip Code:44615-1434
Mailing Address - Country:US
Mailing Address - Phone:330-418-1614
Mailing Address - Fax:
Practice Address - Street 1:1341 MARKET AVE N
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:OH
Practice Address - Zip Code:44714-2605
Practice Address - Country:US
Practice Address - Phone:330-453-8252
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-26
Last Update Date:2012-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH140788MIV164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2901131Medicaid