Provider Demographics
NPI:1023567351
Name:BOBB, STACY
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:
Last Name:BOBB
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3731 HEATH TRCE
Mailing Address - Street 2:
Mailing Address - City:CANAL WINCHESTER
Mailing Address - State:OH
Mailing Address - Zip Code:43110-7703
Mailing Address - Country:US
Mailing Address - Phone:614-330-6494
Mailing Address - Fax:
Practice Address - Street 1:3731 HEATH TRCE
Practice Address - Street 2:
Practice Address - City:CANAL WINCHESTER
Practice Address - State:OH
Practice Address - Zip Code:43110-7703
Practice Address - Country:US
Practice Address - Phone:614-330-6494
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-28
Last Update Date:2016-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHLPN139999164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse