Provider Demographics
NPI:1033841721
Name:STANLEY, TIMOTHY
Entity Type:Individual
Prefix:MR
First Name:TIMOTHY
Middle Name:
Last Name:STANLEY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5031 FREDERICA ST
Mailing Address - Street 2:
Mailing Address - City:OWENSBORO
Mailing Address - State:KY
Mailing Address - Zip Code:42301-7410
Mailing Address - Country:US
Mailing Address - Phone:270-685-3090
Mailing Address - Fax:270-685-3039
Practice Address - Street 1:5031 FREDERICA ST
Practice Address - Street 2:
Practice Address - City:OWENSBORO
Practice Address - State:KY
Practice Address - Zip Code:42301-7410
Practice Address - Country:US
Practice Address - Phone:270-685-3090
Practice Address - Fax:270-685-3039
Is Sole Proprietor?:No
Enumeration Date:2022-06-30
Last Update Date:2022-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY261293156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician