Provider Demographics
NPI:1285024588
Name:POE, STACEY MARIE
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:MARIE
Last Name:POE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:STACEY
Other - Middle Name:MARIE
Other - Last Name:MOSSOR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6460 HARRISON AVE STE 200
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45247-7958
Mailing Address - Country:US
Mailing Address - Phone:513-941-4999
Mailing Address - Fax:513-694-0168
Practice Address - Street 1:25 WHITNEY DR STE 122
Practice Address - Street 2:
Practice Address - City:MILFORD
Practice Address - State:OH
Practice Address - Zip Code:45150-8400
Practice Address - Country:US
Practice Address - Phone:513-941-4999
Practice Address - Fax:513-694-0168
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-26
Last Update Date:2023-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRN.355077163W00000X
OHAPRN.CNP.18957363LF0000X, 363LF0000X
OH18957363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0161593Medicaid