Provider Demographics
NPI:1164488755
Name:STANLEY, KATHERINE R (CFM)
Entity Type:Individual
Prefix:
First Name:KATHERINE
Middle Name:R
Last Name:STANLEY
Suffix:
Gender:F
Credentials:CFM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2830 MAPLEWOOD AVE STE A
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27103-4114
Mailing Address - Country:US
Mailing Address - Phone:336-331-3480
Mailing Address - Fax:336-793-1218
Practice Address - Street 1:2830 MAPLEWOOD AVE STE A
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-4114
Practice Address - Country:US
Practice Address - Phone:336-331-3480
Practice Address - Fax:336-793-1218
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-24
Last Update Date:2022-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
224900000X
NC23483225000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225000000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotic Fitter
No224900000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMastectomy Fitter
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7701864Medicaid
NC7701864Medicaid