Provider Demographics
NPI:1043686595
Name:THACKER-NEWSOME, STACY ANN (MA, LBD)
Entity Type:Individual
Prefix:MRS
First Name:STACY
Middle Name:ANN
Last Name:THACKER-NEWSOME
Suffix:
Gender:F
Credentials:MA, LBD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15903 STATE ROAD 60
Mailing Address - Street 2:
Mailing Address - City:BORDEN
Mailing Address - State:IN
Mailing Address - Zip Code:47106-8629
Mailing Address - Country:US
Mailing Address - Phone:606-831-1020
Mailing Address - Fax:
Practice Address - Street 1:15903 STATE ROAD 60
Practice Address - Street 2:
Practice Address - City:BORDEN
Practice Address - State:IN
Practice Address - Zip Code:47106-8629
Practice Address - Country:US
Practice Address - Phone:606-831-1020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-19
Last Update Date:2015-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist