Provider Demographics
NPI:1174237325
Name:ROBERTSON, STACY LINN (LPN)
Entity type:Individual
Prefix:
First Name:STACY
Middle Name:LINN
Last Name:ROBERTSON
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2285 BENDEN DR
Mailing Address - Street 2:
Mailing Address - City:WOOSTER
Mailing Address - State:OH
Mailing Address - Zip Code:44691-2568
Mailing Address - Country:US
Mailing Address - Phone:330-264-9029
Mailing Address - Fax:
Practice Address - Street 1:6738 STATE ROUTE 93 NW
Practice Address - Street 2:
Practice Address - City:DUNDEE
Practice Address - State:OH
Practice Address - Zip Code:44624-8300
Practice Address - Country:US
Practice Address - Phone:330-432-6142
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-12
Last Update Date:2024-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH123709164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse