Provider Demographics
NPI:1972999787
Name:MENCKE, STACIE
Entity Type:Individual
Prefix:
First Name:STACIE
Middle Name:
Last Name:MENCKE
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 1:5195 MAYFIELD RD
Mailing Address - Street 2:SUITE 10
Mailing Address - City:LYNDHURST
Mailing Address - State:OH
Mailing Address - Zip Code:44124-2464
Mailing Address - Country:US
Mailing Address - Phone:440-720-1810
Mailing Address - Fax:440-720-1814
Practice Address - Street 1:5195 MAYFIELD RD
Practice Address - Street 2:SUITE 10
Practice Address - City:LYNDHURST
Practice Address - State:OH
Practice Address - Zip Code:44124-2464
Practice Address - Country:US
Practice Address - Phone:440-720-1810
Practice Address - Fax:440-720-1814
Is Sole Proprietor?:No
Enumeration Date:2015-04-08
Last Update Date:2015-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH33.015830247200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other