Provider Demographics
NPI:1114898616
Name:LYCANS, COLLEEN MARIE
Entity type:Individual
Prefix:
First Name:COLLEEN
Middle Name:MARIE
Last Name:LYCANS
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 1:2625 CHAMBERLAIN RD
Mailing Address - Street 2:
Mailing Address - City:FAIRLAWN
Mailing Address - State:OH
Mailing Address - Zip Code:44333-4173
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2625 CHAMBERLAIN RD
Practice Address - Street 2:
Practice Address - City:FAIRLAWN
Practice Address - State:OH
Practice Address - Zip Code:44333-4173
Practice Address - Country:US
Practice Address - Phone:330-715-6351
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-09-16
Last Update Date:2025-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH376J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376J00000XNursing Service Related ProvidersHomemaker