Provider Demographics
NPI:1710617915
Name:YARBROUGH, STACEY LANETTE
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:LANETTE
Last Name:YARBROUGH
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 1:13 AMANDAS CT NW
Mailing Address - Street 2:
Mailing Address - City:CARTERSVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30121-4782
Mailing Address - Country:US
Mailing Address - Phone:470-731-4967
Mailing Address - Fax:
Practice Address - Street 1:13 AMANDAS CT NW
Practice Address - Street 2:
Practice Address - City:CARTERSVILLE
Practice Address - State:GA
Practice Address - Zip Code:30121-4782
Practice Address - Country:US
Practice Address - Phone:470-731-4967
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-13
Last Update Date:2022-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0297109021744P3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1744P3200XOther Service ProvidersSpecialistProsthetics Case ManagementGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA029710902Other029710902