Provider Demographics
NPI:1134903867
Name:NIESE, LACEY
Entity type:Individual
Prefix:
First Name:LACEY
Middle Name:
Last Name:NIESE
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 1:511 PERRY ST
Mailing Address - Street 2:
Mailing Address - City:DEFIANCE
Mailing Address - State:OH
Mailing Address - Zip Code:43512-2123
Mailing Address - Country:US
Mailing Address - Phone:419-782-9920
Mailing Address - Fax:419-784-2523
Practice Address - Street 1:511 PERRY ST
Practice Address - Street 2:
Practice Address - City:DEFIANCE
Practice Address - State:OH
Practice Address - Zip Code:43512-2123
Practice Address - Country:US
Practice Address - Phone:419-782-9920
Practice Address - Fax:419-784-2523
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-23
Last Update Date:2023-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHLPN.172803.MEDS-IV164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse