Provider Demographics
NPI:1235826488
Name:STACY, KENZIE
Entity Type:Individual
Prefix:
First Name:KENZIE
Middle Name:
Last Name:STACY
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 1:100 MCGIBNEY RD APT C3
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:OH
Mailing Address - Zip Code:43050-1227
Mailing Address - Country:US
Mailing Address - Phone:234-301-7486
Mailing Address - Fax:
Practice Address - Street 1:100 MCGIBNEY RD APT C3
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:OH
Practice Address - Zip Code:43050-1227
Practice Address - Country:US
Practice Address - Phone:234-301-7486
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-19
Last Update Date:2023-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care