Provider Demographics
NPI:1053843292
Name:MAGGIO, STACY BLACKWELL (SA-C)
Entity Type:Individual
Prefix:MRS
First Name:STACY
Middle Name:BLACKWELL
Last Name:MAGGIO
Suffix:
Gender:F
Credentials:SA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1150 ROBERT BLVD
Mailing Address - Street 2:SUITE 240
Mailing Address - City:SLIDELL
Mailing Address - State:LA
Mailing Address - Zip Code:70458-2004
Mailing Address - Country:US
Mailing Address - Phone:985-718-9392
Mailing Address - Fax:985-249-5092
Practice Address - Street 1:1150 ROBERT BLVD
Practice Address - Street 2:SUITE 240
Practice Address - City:SLIDELL
Practice Address - State:LA
Practice Address - Zip Code:70458-2004
Practice Address - Country:US
Practice Address - Phone:985-718-9392
Practice Address - Fax:985-249-5092
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-28
Last Update Date:2017-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA246ZC0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant