Provider Demographics
NPI:1770018160
Name:FISSEL, STACY
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:
Last Name:FISSEL
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 1:2129 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BELLEFONTAINE
Mailing Address - State:OH
Mailing Address - Zip Code:43311-1557
Mailing Address - Country:US
Mailing Address - Phone:937-592-3464
Mailing Address - Fax:937-593-2343
Practice Address - Street 1:2129 S MAIN ST
Practice Address - Street 2:
Practice Address - City:BELLEFONTAINE
Practice Address - State:OH
Practice Address - Zip Code:43311-1557
Practice Address - Country:US
Practice Address - Phone:937-592-3464
Practice Address - Fax:937-593-2343
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-24
Last Update Date:2017-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH03122787183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist