Provider Demographics
NPI:1134679012
Name:HARRIS, STACI SITHEMBILE (NP)
Entity Type:Individual
Prefix:MRS
First Name:STACI
Middle Name:SITHEMBILE
Last Name:HARRIS
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2334 SOUTH 41ST STREET
Mailing Address - Street 2:LIBERTY HEALTHCARE GROUP
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28403
Mailing Address - Country:US
Mailing Address - Phone:704-695-1421
Mailing Address - Fax:704-694-7748
Practice Address - Street 1:2550 S 41ST ST
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28403-5519
Practice Address - Country:US
Practice Address - Phone:704-695-1421
Practice Address - Fax:704-694-7748
Is Sole Proprietor?:No
Enumeration Date:2016-10-04
Last Update Date:2021-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5009104363LA2200X, 363LP2300X
SC20490363LP2300X, 363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC0000000Medicaid
NC0000000Medicaid
SC0000000Medicare UPIN
NC0000000Medicare UPIN