Provider Demographics
NPI:1134686124
Name:CLARK, STACEY DEANN
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:DEANN
Last Name:CLARK
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 1:1400 BARRON LN
Mailing Address - Street 2:
Mailing Address - City:AXTELL
Mailing Address - State:TX
Mailing Address - Zip Code:76624-1394
Mailing Address - Country:US
Mailing Address - Phone:770-255-8982
Mailing Address - Fax:
Practice Address - Street 1:1400 BARRON LN
Practice Address - Street 2:
Practice Address - City:AXTELL
Practice Address - State:TX
Practice Address - Zip Code:76624-1394
Practice Address - Country:US
Practice Address - Phone:770-255-8982
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-26
Last Update Date:2019-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX347556164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse