Provider Demographics
NPI:1093114837
Name:STREET, STACY LYNN
Entity Type:Individual
Prefix:MS
First Name:STACY
Middle Name:LYNN
Last Name:STREET
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2401 LARKSPUR DRIVE
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27405-5431
Mailing Address - Country:US
Mailing Address - Phone:336-212-2730
Mailing Address - Fax:
Practice Address - Street 1:2401 LARKSPUR DRIVE
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27405-5431
Practice Address - Country:US
Practice Address - Phone:336-212-2730
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-18
Last Update Date:2014-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC372600000X, 374U00000X, 376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
No372600000XNursing Service Related ProvidersAdult Companion
No376K00000XNursing Service Related ProvidersNurse's Aide