Provider Demographics
NPI:1669916789
Name:ANCONA, LACRETIA
Entity type:Individual
Prefix:
First Name:LACRETIA
Middle Name:
Last Name:ANCONA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:LACRETIA
Other - Middle Name:
Other - Last Name:MILNER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 181505
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:45018-1524
Mailing Address - Country:US
Mailing Address - Phone:513-410-5008
Mailing Address - Fax:
Practice Address - Street 1:700 WESSEL DR #181505
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:OH
Practice Address - Zip Code:45014
Practice Address - Country:US
Practice Address - Phone:513-410-5008
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-08
Last Update Date:2017-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH3119351Medicaid