Provider Demographics
NPI:1114118585
Name:ANNA FAYE STANLEY OD PC
Entity Type:Organization
Organization Name:ANNA FAYE STANLEY OD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ANNA
Authorized Official - Middle Name:FAYE
Authorized Official - Last Name:STANLEY
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:270-726-8283
Mailing Address - Street 1:1102 BROOKHAVEN AVE
Mailing Address - Street 2:
Mailing Address - City:RUSSELLVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:42276-1020
Mailing Address - Country:US
Mailing Address - Phone:270-776-8127
Mailing Address - Fax:
Practice Address - Street 1:120 SAM WALTON DR
Practice Address - Street 2:VISION CENTER
Practice Address - City:RUSSELLVILLE
Practice Address - State:KY
Practice Address - Zip Code:42276-9311
Practice Address - Country:US
Practice Address - Phone:270-726-8283
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-09
Last Update Date:2014-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1476DT152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY77340438Medicaid
KYDF8467OtherRAILROAD MEDICARE
KY77340438Medicaid