Provider Demographics
NPI:1528492147
Name:DICKEY, STACEY WYLENE (LPN)
Entity type:Individual
Prefix:MISS
First Name:STACEY
Middle Name:WYLENE
Last Name:DICKEY
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1451 PLAIN AVE NE
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44714-2441
Mailing Address - Country:US
Mailing Address - Phone:330-933-1749
Mailing Address - Fax:
Practice Address - Street 1:1451 PLAIN AVE NE
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:OH
Practice Address - Zip Code:44714-2441
Practice Address - Country:US
Practice Address - Phone:330-933-1749
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-30
Last Update Date:2013-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH141351164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse