Provider Demographics
NPI:1326681230
Name:LE, STACEY MAY
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:MAY
Last Name:LE
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 1:1030 WHISTLING SWAN PL
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30066-2782
Mailing Address - Country:US
Mailing Address - Phone:678-472-4297
Mailing Address - Fax:
Practice Address - Street 1:61 WHITCHER ST NE STE 4100
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30060-1181
Practice Address - Country:US
Practice Address - Phone:770-590-4180
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-23
Last Update Date:2019-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN212448363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner