Provider Demographics
NPI:1861733396
Name:MCNICKLE, LORI (CPED, RFOM)
Entity type:Individual
Prefix:
First Name:LORI
Middle Name:
Last Name:MCNICKLE
Suffix:
Gender:F
Credentials:CPED, RFOM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4663 WHIPPLE AVE NW
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44718-2615
Mailing Address - Country:US
Mailing Address - Phone:330-479-0020
Mailing Address - Fax:330-493-5759
Practice Address - Street 1:4663 WHIPPLE AVE NW
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:OH
Practice Address - Zip Code:44718-2615
Practice Address - Country:US
Practice Address - Phone:330-479-0020
Practice Address - Fax:330-493-5759
Is Sole Proprietor?:No
Enumeration Date:2013-03-07
Last Update Date:2013-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHLPED32224L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224L00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPedorthist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2002862Medicaid