Provider Demographics
NPI:1417371691
Name:SALE, STACEY (PA-C)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:
Last Name:SALE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 950248
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40295-0248
Mailing Address - Country:US
Mailing Address - Phone:502-489-5730
Mailing Address - Fax:502-489-5751
Practice Address - Street 1:3303 FERN VALLEY RD
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40213-3529
Practice Address - Country:US
Practice Address - Phone:502-964-4889
Practice Address - Fax:502-964-9976
Is Sole Proprietor?:No
Enumeration Date:2014-02-10
Last Update Date:2020-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYTC258363A00000X
KYPA1884363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100273800Medicaid