Provider Demographics
NPI:1801901681
Name:VERSIACKAS, MARJORIE ANN (LPN)
Entity type:Individual
Prefix:MRS
First Name:MARJORIE
Middle Name:ANN
Last Name:VERSIACKAS
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3695 FOX AVE NE
Mailing Address - Street 2:
Mailing Address - City:MINERVA
Mailing Address - State:OH
Mailing Address - Zip Code:44657
Mailing Address - Country:US
Mailing Address - Phone:330-862-2662
Mailing Address - Fax:330-862-2662
Practice Address - Street 1:3695 FOX AVE NE
Practice Address - Street 2:
Practice Address - City:MINERVA
Practice Address - State:OH
Practice Address - Zip Code:44657
Practice Address - Country:US
Practice Address - Phone:330-862-2662
Practice Address - Fax:330-862-2662
Is Sole Proprietor?:No
Enumeration Date:2006-08-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPN069347164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse