Provider Demographics
NPI:1447216023
Name:BOULTON, STACY (MD)
Entity Type:Individual
Prefix:DR
First Name:STACY
Middle Name:
Last Name:BOULTON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6907 BURLINGTON PIKE
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:KY
Mailing Address - Zip Code:41042-1618
Mailing Address - Country:US
Mailing Address - Phone:859-525-1846
Mailing Address - Fax:859-647-3355
Practice Address - Street 1:6907 BURLINGTON PIKE
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:KY
Practice Address - Zip Code:41042-1618
Practice Address - Country:US
Practice Address - Phone:859-525-1846
Practice Address - Fax:859-647-3355
Is Sole Proprietor?:No
Enumeration Date:2006-04-24
Last Update Date:2007-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35084722207VG0400X, 207VX0000X
KY40489207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
No207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
No207VX0000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyObstetrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2494840Medicaid
OH2494840Medicaid