Provider Demographics
NPI:1073133716
Name:POULIOT, STACEY (CPM, LM)
Entity Type:Individual
Prefix:MRS
First Name:STACEY
Middle Name:
Last Name:POULIOT
Suffix:
Gender:F
Credentials:CPM, LM
Other - Prefix:
Other - First Name:STACEY
Other - Middle Name:
Other - Last Name:ALEXANDER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:CPM, LM
Mailing Address - Street 1:6007 CHINABERRY CT
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28269-9174
Mailing Address - Country:US
Mailing Address - Phone:704-737-5895
Mailing Address - Fax:
Practice Address - Street 1:6007 CHINABERRY CT
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28269-9174
Practice Address - Country:US
Practice Address - Phone:704-737-5895
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-22
Last Update Date:2020-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCLMW0090176B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes176B00000XOther Service ProvidersMidwife