Provider Demographics
NPI:1558052597
Name:SALJOUGHI, STACY G
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:G
Last Name:SALJOUGHI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:STACY
Other - Middle Name:SHANETTE
Other - Last Name:GHOLSTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:136 FLYAWAY LN
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76120-1634
Mailing Address - Country:US
Mailing Address - Phone:817-891-2471
Mailing Address - Fax:
Practice Address - Street 1:921 CRAWFORD ST APT 4106
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-3481
Practice Address - Country:US
Practice Address - Phone:817-891-2471
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-19
Last Update Date:2023-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant