Healthcare Provider Details

I. General information

NPI: 1982239943
Provider Name (Legal Business Name): LACHILLE MCRAE LPN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/10/2020
Last Update Date: 03/30/2020
Certification Date: 03/30/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

284 BROADWAY AVE
YOUNGSTOWN OH
44504-1752
US

IV. Provider business mailing address

535 MARMION AVE
YOUNGSTOWN OH
44502-2323
US

V. Phone/Fax

Practice location:
  • Phone: 330-743-5309
  • Fax:
Mailing address:
  • Phone: 330-782-5664
  • Fax: 330-782-1614

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License NumberLPN119742
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: