Provider Demographics
NPI:1770184905
Name:STACY, TAMI S
Entity Type:Individual
Prefix:
First Name:TAMI
Middle Name:S
Last Name:STACY
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 1:122 PINE RIDGE AVE # 8244
Mailing Address - Street 2:
Mailing Address - City:MOUNT ORAB
Mailing Address - State:OH
Mailing Address - Zip Code:45154-8244
Mailing Address - Country:US
Mailing Address - Phone:513-518-0785
Mailing Address - Fax:
Practice Address - Street 1:122 PINE RIDGE AVE # 8244
Practice Address - Street 2:
Practice Address - City:MOUNT ORAB
Practice Address - State:OH
Practice Address - Zip Code:45154-8244
Practice Address - Country:US
Practice Address - Phone:513-518-0785
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-04
Last Update Date:2020-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide