Provider Demographics
NPI:1699400952
Name:PHILLIPS, STACEY LEANN
Entity Type:Individual
Prefix:MISS
First Name:STACEY
Middle Name:LEANN
Last Name:PHILLIPS
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 1:19 16TH ST
Mailing Address - Street 2:
Mailing Address - City:MCMECHEN
Mailing Address - State:WV
Mailing Address - Zip Code:26040-1321
Mailing Address - Country:US
Mailing Address - Phone:304-517-6481
Mailing Address - Fax:
Practice Address - Street 1:19 16TH ST
Practice Address - Street 2:
Practice Address - City:MCMECHEN
Practice Address - State:WV
Practice Address - Zip Code:26040-1321
Practice Address - Country:US
Practice Address - Phone:304-517-6481
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-20
Last Update Date:2022-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes373H00000XNursing Service Related ProvidersDay Training/Habilitation Specialist