Provider Demographics
NPI:1275938391
Name:DAVIS, STACY (IBCLC)
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:
Last Name:DAVIS
Suffix:
Gender:F
Credentials:IBCLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14210 GLENWOOD ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48205-2829
Mailing Address - Country:US
Mailing Address - Phone:313-922-4818
Mailing Address - Fax:248-809-9888
Practice Address - Street 1:14210 GLENWOOD ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48205-2829
Practice Address - Country:US
Practice Address - Phone:313-922-4818
Practice Address - Fax:248-809-9888
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-31
Last Update Date:2014-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIL-56572174N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174N00000XOther Service ProvidersLactation Consultant, Non-RN