Provider Demographics
NPI:1508240565
Name:WHITZELL, STACY LEN
Entity Type:Individual
Prefix:MR
First Name:STACY
Middle Name:LEN
Last Name:WHITZELL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:STACY
Other - Middle Name:LEN
Other - Last Name:WHETZELL
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 770
Mailing Address - Street 2:
Mailing Address - City:TRENTON
Mailing Address - State:GA
Mailing Address - Zip Code:30752-0770
Mailing Address - Country:US
Mailing Address - Phone:423-847-2422
Mailing Address - Fax:
Practice Address - Street 1:5708 UPTAIN RD STE 1100
Practice Address - Street 2:
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37411-5687
Practice Address - Country:US
Practice Address - Phone:423-847-2422
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-19
Last Update Date:2015-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN10000000164083747P1801X, 372600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes372600000XNursing Service Related ProvidersAdult Companion
No3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant