Provider Demographics
NPI:1720449440
Name:DEWITT, STACIE LYNN
Entity Type:Individual
Prefix:
First Name:STACIE
Middle Name:LYNN
Last Name:DEWITT
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:PO BOX 391
Mailing Address - Street 2:
Mailing Address - City:VERMILION
Mailing Address - State:OH
Mailing Address - Zip Code:44089-0391
Mailing Address - Country:US
Mailing Address - Phone:440-989-6420
Mailing Address - Fax:
Practice Address - Street 1:460 NANTUCKET PL
Practice Address - Street 2:APT M
Practice Address - City:VERMILION
Practice Address - State:OH
Practice Address - Zip Code:44089-3281
Practice Address - Country:US
Practice Address - Phone:440-989-6420
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-08
Last Update Date:2016-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH102938217-00Medicaid