Basic Information
| Provider Information | |||||||||
| NPI: | 1487151833 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | EMERINE | ||||||||
| FirstName: | LACIE | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MSN, RN, CNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1980 TAMARACK RD | ||||||||
| Address2: | |||||||||
| City: | NEWARK | ||||||||
| State: | OH | ||||||||
| PostalCode: | 430551363 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2205647520 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1980 TAMARACK RD | ||||||||
| Address2: | |||||||||
| City: | NEWARK | ||||||||
| State: | OH | ||||||||
| PostalCode: | 430551363 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2205647520 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/11/2018 | ||||||||
| LastUpdateDate: | 09/09/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 09/09/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | F07181293 | OH | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363L00000X | 023300 | OH | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | F07181293 | 01 | OH | AANP | OTHER |