Provider Demographics
NPI:1659784841
Name:FABRY, STACIE
Entity Type:Individual
Prefix:
First Name:STACIE
Middle Name:
Last Name:FABRY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:424 COUNTY ROAD 20
Mailing Address - Street 2:
Mailing Address - City:DILLONVALE
Mailing Address - State:OH
Mailing Address - Zip Code:43917-7948
Mailing Address - Country:US
Mailing Address - Phone:740-381-5521
Mailing Address - Fax:
Practice Address - Street 1:424 COUNTY ROAD 20
Practice Address - Street 2:
Practice Address - City:DILLONVALE
Practice Address - State:OH
Practice Address - Zip Code:43917-7948
Practice Address - Country:US
Practice Address - Phone:740-381-5521
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-05
Last Update Date:2014-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0103263Medicaid