Provider Demographics
NPI:1245826189
Name:SECRIST, STANLEY
Entity type:Individual
Prefix:
First Name:STANLEY
Middle Name:
Last Name:SECRIST
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1825 NOTTINGHAM CT
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:44904-1784
Mailing Address - Country:US
Mailing Address - Phone:419-564-3079
Mailing Address - Fax:
Practice Address - Street 1:1825 NOTTINGHAM CT
Practice Address - Street 2:
Practice Address - City:MANSFIELD
Practice Address - State:OH
Practice Address - Zip Code:44904-1784
Practice Address - Country:US
Practice Address - Phone:419-564-3079
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-15
Last Update Date:2020-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH376J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376J00000XNursing Service Related ProvidersHomemaker