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General NPI Number Information
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NPI Number | 1770173874
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Entity Type | Individual
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Provider Name | LACEY POLEWSKI
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Gender | Female
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Dates
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Enumeration Date | 01/22/2021
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Last Update Date | 01/22/2021
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Provider Practice Location Address
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Address Line | 3333 W TECH RD STE 220
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City | MIAMISBURG
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State | OH
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Zip | 45342-0956
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Country | US
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Telephone | 937-885-4475
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Fax |
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Provider Business Mailing Address
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Address Line | 105 SYCAMORE SPRINGS DR
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City | SPRINGBORO
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State | OH
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Zip | 45066-9569
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Country | US
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Telephone | 937-239-7256
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LP2300X
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Taxonomy Name | Primary Care Nurse Practitioner
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License Number | APRN.CNP.0028287
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License Number State | OH
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