Provider Demographics
NPI:1083281000
Name:BOYLES, STACEY R
Entity Type:Individual
Prefix:MR
First Name:STACEY
Middle Name:R
Last Name:BOYLES
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 1:1702 KIRKWOOD HWY STE 101
Mailing Address - Street 2:
Mailing Address - City:ELSMERE
Mailing Address - State:DE
Mailing Address - Zip Code:19805-4939
Mailing Address - Country:US
Mailing Address - Phone:302-777-0778
Mailing Address - Fax:
Practice Address - Street 1:1702 KIRKWOOD HWY STE 101
Practice Address - Street 2:
Practice Address - City:ELSMERE
Practice Address - State:DE
Practice Address - Zip Code:19805-4939
Practice Address - Country:US
Practice Address - Phone:302-507-1075
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-08
Last Update Date:2021-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEMT-0004819225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist