Provider Demographics
NPI:1417486655
Name:ELWOOD, STACIE NETTLES (ATC)
Entity Type:Individual
Prefix:
First Name:STACIE
Middle Name:NETTLES
Last Name:ELWOOD
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:STACIE
Other - Middle Name:LYNN
Other - Last Name:NETTLES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:ATC
Mailing Address - Street 1:9800 DELEMAR HWY
Mailing Address - Street 2:
Mailing Address - City:SUMMERVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29485-7842
Mailing Address - Country:US
Mailing Address - Phone:843-695-4900
Mailing Address - Fax:
Practice Address - Street 1:9800 DELEMAR HWY
Practice Address - Street 2:
Practice Address - City:SUMMERVILLE
Practice Address - State:SC
Practice Address - Zip Code:29485-7842
Practice Address - Country:US
Practice Address - Phone:843-695-4900
Practice Address - Fax:843-695-4900
Is Sole Proprietor?:No
Enumeration Date:2017-06-10
Last Update Date:2017-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC0698025532255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer