Provider Demographics
NPI:1699408153
Name:OMAR, STACY MARIE
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:MARIE
Last Name:OMAR
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 1:2222 3RD ST NE
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44704-2110
Mailing Address - Country:US
Mailing Address - Phone:330-575-3026
Mailing Address - Fax:
Practice Address - Street 1:2222 3RD ST NE
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:OH
Practice Address - Zip Code:44704-2110
Practice Address - Country:US
Practice Address - Phone:330-575-3026
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-01
Last Update Date:2022-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes374U00000XNursing Service Related ProvidersHome Health AideGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHSJ630608Medicaid