Provider Demographics
NPI:1437484748
Name:NISHIBUN, STACY CLARK (MAE, IECE)
Entity Type:Individual
Prefix:MRS
First Name:STACY
Middle Name:CLARK
Last Name:NISHIBUN
Suffix:
Gender:F
Credentials:MAE, IECE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 CHAPMAN ST
Mailing Address - Street 2:
Mailing Address - City:FRANKLIN
Mailing Address - State:KY
Mailing Address - Zip Code:42134-1647
Mailing Address - Country:US
Mailing Address - Phone:270-535-2928
Mailing Address - Fax:
Practice Address - Street 1:400 CHAPMAN ST
Practice Address - Street 2:
Practice Address - City:FRANKLIN
Practice Address - State:KY
Practice Address - Zip Code:42134-1647
Practice Address - Country:US
Practice Address - Phone:270-535-2928
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-05
Last Update Date:2009-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist