Provider Demographics
NPI:1659815462
Name:HOUSE, STACY
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:
Last Name:HOUSE
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 1:3910 ELKIN RIDGE DR # B
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27858-1020
Mailing Address - Country:US
Mailing Address - Phone:252-508-1113
Mailing Address - Fax:
Practice Address - Street 1:3910 ELKIN RIDGE DR # B
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:NC
Practice Address - Zip Code:27858-1020
Practice Address - Country:US
Practice Address - Phone:252-508-1113
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-13
Last Update Date:2016-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor