Basic Information
| Provider Information | |||||||||
| NPI: | 1255866794 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RUGGLES | ||||||||
| FirstName: | STACY | ||||||||
| MiddleName: | RENEE | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LPN | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 108 | ||||||||
| Address2: | |||||||||
| City: | IRONTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 456380108 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7405321613 | ||||||||
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| Practice Location | |||||||||
| Address1: | 700 PARK AVENUE | ||||||||
| Address2: | |||||||||
| City: | IRONTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 45638 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7405321613 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/21/2017 | ||||||||
| LastUpdateDate: | 04/17/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 164W00000X | LPN.147041.MEDS-IV | OH | Y | Nursing Service Providers | Licensed Practical Nurse |
ID Information
| ID | Type | State | Issuer | Description | 0219240 | 05 | OH | MEDICAID |