Provider Demographics
NPI:1851894844
Name:VANSICKLE, DYAN (DTR, IBCLC, CLC)
Entity Type:Individual
Prefix:
First Name:DYAN
Middle Name:
Last Name:VANSICKLE
Suffix:
Gender:F
Credentials:DTR, IBCLC, CLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1680 CLAY BANK RD
Mailing Address - Street 2:
Mailing Address - City:LOGAN
Mailing Address - State:OH
Mailing Address - Zip Code:43138-9187
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1680 CLAY BANK RD
Practice Address - Street 2:
Practice Address - City:LOGAN
Practice Address - State:OH
Practice Address - Zip Code:43138-9187
Practice Address - Country:US
Practice Address - Phone:740-603-6081
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-15
Last Update Date:2018-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH136A00000X, 174N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174N00000XOther Service ProvidersLactation Consultant, Non-RN
No136A00000XDietary & Nutritional Service ProvidersDietetic Technician, RegisteredGroup - Single Specialty