Provider Demographics
NPI:1447964762
Name:LACEY, SAMANTHA DAWN
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:DAWN
Last Name:LACEY
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 1:1604 ANDREW ST
Mailing Address - Street 2:
Mailing Address - City:PARKERSBURG
Mailing Address - State:WV
Mailing Address - Zip Code:26101-5022
Mailing Address - Country:US
Mailing Address - Phone:614-783-2618
Mailing Address - Fax:
Practice Address - Street 1:1604 ANDREW ST
Practice Address - Street 2:
Practice Address - City:PARKERSBURG
Practice Address - State:WV
Practice Address - Zip Code:26101-5022
Practice Address - Country:US
Practice Address - Phone:614-783-2618
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-11
Last Update Date:2023-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant