Provider Demographics
NPI:1518450444
Name:STACEY, KIANA NICOLE
Entity Type:Individual
Prefix:
First Name:KIANA
Middle Name:NICOLE
Last Name:STACEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KIANA
Other - Middle Name:NICOLE
Other - Last Name:LINEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2444 STOREN ST APT B
Mailing Address - Street 2:
Mailing Address - City:NORTH CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29406-9834
Mailing Address - Country:US
Mailing Address - Phone:843-267-1229
Mailing Address - Fax:
Practice Address - Street 1:2444 STOREN ST APT B
Practice Address - Street 2:
Practice Address - City:NORTH CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29406-9834
Practice Address - Country:US
Practice Address - Phone:843-267-1229
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-14
Last Update Date:2018-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health