Provider Demographics
NPI:1437530698
Name:VAWTER, STACEY NICOLE
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:NICOLE
Last Name:VAWTER
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 1:2593 HUNTSVILLE HWY
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37334-3772
Mailing Address - Country:US
Mailing Address - Phone:256-683-7392
Mailing Address - Fax:
Practice Address - Street 1:200 NURSING HOME LN
Practice Address - Street 2:
Practice Address - City:PIKEVILLE
Practice Address - State:KY
Practice Address - Zip Code:41501-6896
Practice Address - Country:US
Practice Address - Phone:606-639-4840
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-13
Last Update Date:2020-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN46002699A235Z00000X
AL4226235Z00000X
KY251357235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist