Provider Demographics
NPI:1740616721
Name:WILLIFORD, STACEY HODGES (NP)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:HODGES
Last Name:WILLIFORD
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2173 MOUNT ZION RD
Mailing Address - Street 2:
Mailing Address - City:WARTHEN
Mailing Address - State:GA
Mailing Address - Zip Code:31094-4259
Mailing Address - Country:US
Mailing Address - Phone:478-412-2880
Mailing Address - Fax:
Practice Address - Street 1:601 FERNCREST DR BLDG A
Practice Address - Street 2:
Practice Address - City:SANDERSVILLE
Practice Address - State:GA
Practice Address - Zip Code:31082-1800
Practice Address - Country:US
Practice Address - Phone:478-412-2880
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-09-23
Last Update Date:2022-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN149431163WG0000X, 363LF0000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163WG0000XNursing Service ProvidersRegistered NurseGeneral Practice
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily