Provider Demographics
NPI:1669298261
Name:PHILLIPS, LACEY NICHOLE (LPN)
Entity type:Individual
Prefix:
First Name:LACEY
Middle Name:NICHOLE
Last Name:PHILLIPS
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:LACEY
Other - Middle Name:NICHOLE
Other - Last Name:KEEFER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPN
Mailing Address - Street 1:4600 MONTGOMERY RD STE 400
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45212-2600
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1012 E PERKINS AVE
Practice Address - Street 2:
Practice Address - City:SANDUSKY
Practice Address - State:OH
Practice Address - Zip Code:44870-5070
Practice Address - Country:US
Practice Address - Phone:833-510-4357
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-11-27
Last Update Date:2024-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHLPN.131079.MEDS-IV164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse