Provider Demographics
NPI:1124564448
Name:HARRIS, STACEY
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:
Last Name:HARRIS
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 1:21 S BEECHTREE
Mailing Address - Street 2:
Mailing Address - City:GRAND HAVEN
Mailing Address - State:MI
Mailing Address - Zip Code:49417
Mailing Address - Country:US
Mailing Address - Phone:616-414-9440
Mailing Address - Fax:844-364-2565
Practice Address - Street 1:21 S BEECHTREE ST
Practice Address - Street 2:
Practice Address - City:GRAND HAVEN
Practice Address - State:MI
Practice Address - Zip Code:49417-1603
Practice Address - Country:US
Practice Address - Phone:616-414-9440
Practice Address - Fax:844-364-2565
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-10
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI35-2578452251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health