Provider Demographics
NPI:1346992625
Name:KING, LAVADA S
Entity type:Individual
Prefix:
First Name:LAVADA
Middle Name:S
Last Name:KING
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 1:344 GRACE STREET
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:44902-1571
Mailing Address - Country:US
Mailing Address - Phone:419-612-1581
Mailing Address - Fax:
Practice Address - Street 1:344 GRACE ST
Practice Address - Street 2:
Practice Address - City:MANSFIELD
Practice Address - State:OH
Practice Address - Zip Code:44902-1173
Practice Address - Country:US
Practice Address - Phone:419-612-1581
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-19
Last Update Date:2024-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
343900000X, 347C00000X, 376J00000X
OH401680850814376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376J00000XNursing Service Related ProvidersHomemaker
No343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
No347C00000XTransportation ServicesPrivate Vehicle
No376K00000XNursing Service Related ProvidersNurse's Aide