Provider Demographics
NPI:1194157206
Name:BOYD, MACEY NICOLE
Entity type:Individual
Prefix:
First Name:MACEY
Middle Name:NICOLE
Last Name:BOYD
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 1:356 KENNEDY DR
Mailing Address - Street 2:
Mailing Address - City:NEW LEXINGTON
Mailing Address - State:OH
Mailing Address - Zip Code:43764-1171
Mailing Address - Country:US
Mailing Address - Phone:740-605-6803
Mailing Address - Fax:
Practice Address - Street 1:356 KENNEDY DR
Practice Address - Street 2:
Practice Address - City:NEW LEXINGTON
Practice Address - State:OH
Practice Address - Zip Code:43764-1171
Practice Address - Country:US
Practice Address - Phone:740-605-6803
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-07-31
Last Update Date:2013-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPTA.08604172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHPTA.08604OtherLICENSE