Provider Demographics
NPI:1053436790
Name:KITCHEN, STACEY R
Entity type:Individual
Prefix:
First Name:STACEY
Middle Name:R
Last Name:KITCHEN
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 1:1175 TOWNSHIP ROAD 1996
Mailing Address - Street 2:
Mailing Address - City:ASHLAND
Mailing Address - State:OH
Mailing Address - Zip Code:44805-9271
Mailing Address - Country:US
Mailing Address - Phone:419-557-8904
Mailing Address - Fax:
Practice Address - Street 1:1175 TOWNSHIP ROAD 1996
Practice Address - Street 2:
Practice Address - City:ASHLAND
Practice Address - State:OH
Practice Address - Zip Code:44805-9271
Practice Address - Country:US
Practice Address - Phone:419-557-8904
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-20
Last Update Date:2012-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPN.150552164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2551055Medicaid