Provider Demographics
NPI:1467214312
Name:STANLEY, RICKY A
Entity Type:Individual
Prefix:
First Name:RICKY
Middle Name:A
Last Name:STANLEY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2511 NEUDORF RD STE J
Mailing Address - Street 2:
Mailing Address - City:CLEMMONS
Mailing Address - State:NC
Mailing Address - Zip Code:27012-8922
Mailing Address - Country:US
Mailing Address - Phone:336-934-4133
Mailing Address - Fax:336-955-2124
Practice Address - Street 1:2511 NEUDORF RD STE J
Practice Address - Street 2:
Practice Address - City:CLEMMONS
Practice Address - State:NC
Practice Address - Zip Code:27012-8922
Practice Address - Country:US
Practice Address - Phone:336-934-4133
Practice Address - Fax:336-955-2124
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-26
Last Update Date:2024-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HC5005253Z00000X
NCHC5005253Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care