Provider Demographics
NPI:1366928830
Name:STACKPOLE, LAUREN (APRN, CNP)
Entity type:Individual
Prefix:
First Name:LAUREN
Middle Name:
Last Name:STACKPOLE
Suffix:
Gender:F
Credentials:APRN, CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1320 CORPORATE DR STE 200
Mailing Address - Street 2:
Mailing Address - City:HUDSON
Mailing Address - State:OH
Mailing Address - Zip Code:44236-4442
Mailing Address - Country:US
Mailing Address - Phone:330-926-3549
Mailing Address - Fax:
Practice Address - Street 1:1320 CORPORATE DR STE 200
Practice Address - Street 2:
Practice Address - City:HUDSON
Practice Address - State:OH
Practice Address - Zip Code:44236-4442
Practice Address - Country:US
Practice Address - Phone:330-926-3549
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-17
Last Update Date:2022-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAPRN.CNP.023209363LF0000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0312235Medicaid