1457027419 NPI number — LACEY ANN SKELTON LEVEL 1 MED AIDE

Table of content: LACEY ANN SKELTON LEVEL 1 MED AIDE (NPI 1457027419)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1457027419 NPI number — LACEY ANN SKELTON LEVEL 1 MED AIDE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SKELTON
Provider First Name:
LACEY
Provider Middle Name:
ANN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LEVEL 1 MED AIDE
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1457027419
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/05/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
18941 CR 305A
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
EMINENCE
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
65466-6268
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
573-226-5426
Provider Business Mailing Address Fax Number:
573-226-5426

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
18941 CR 305A
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EMINENCE
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
65466-6268
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
573-226-5426
Provider Business Practice Location Address Fax Number:
573-226-5426
Provider Enumeration Date:
08/19/2021

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 320900000X , with the licence number:  049124 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 84-1730316 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com