Provider Demographics
NPI:1144020140
Name:LANIER, DARRYL KEITH JR
Entity type:Individual
Prefix:
First Name:DARRYL
Middle Name:KEITH
Last Name:LANIER
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:213 BUCKEYE BLVD APT 5
Mailing Address - Street 2:
Mailing Address - City:PORT CLINTON
Mailing Address - State:OH
Mailing Address - Zip Code:43452-1467
Mailing Address - Country:US
Mailing Address - Phone:419-603-0867
Mailing Address - Fax:
Practice Address - Street 1:430 N BROADWAY ST
Practice Address - Street 2:
Practice Address - City:GREEN SPRINGS
Practice Address - State:OH
Practice Address - Zip Code:44836-9734
Practice Address - Country:US
Practice Address - Phone:419-307-9128
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-03-18
Last Update Date:2025-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAPS.005036175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes175T00000XOther Service ProvidersPeer SpecialistGroup - Multi-Specialty