Provider Demographics
NPI:1467088757
Name:HARRIS, STACY (HOME CARE AGENCY)
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:
Last Name:HARRIS
Suffix:
Gender:F
Credentials:HOME CARE AGENCY
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:900 S ARLINGTON AVE RM 144B
Mailing Address - Street 2:
Mailing Address - City:HARRISBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17109-5030
Mailing Address - Country:US
Mailing Address - Phone:717-370-4976
Mailing Address - Fax:717-412-7390
Practice Address - Street 1:900 S ARLINGTON AVE RM 144B
Practice Address - Street 2:
Practice Address - City:HARRISBURG
Practice Address - State:PA
Practice Address - Zip Code:17109-5030
Practice Address - Country:US
Practice Address - Phone:717-370-4976
Practice Address - Fax:717-412-7390
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-18
Last Update Date:2020-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA11793601374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes374U00000XNursing Service Related ProvidersHome Health AideGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA455288227Medicaid