Provider Demographics
NPI:1790389716
Name:COLLINS, STACEY
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:
Last Name:COLLINS
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 1:382 BROADWAY AVE
Mailing Address - Street 2:
Mailing Address - City:MORGANTOWN
Mailing Address - State:WV
Mailing Address - Zip Code:26505-0364
Mailing Address - Country:US
Mailing Address - Phone:304-599-7743
Mailing Address - Fax:
Practice Address - Street 1:382 BROADWAY AVE
Practice Address - Street 2:
Practice Address - City:MORGANTOWN
Practice Address - State:WV
Practice Address - Zip Code:26505-0364
Practice Address - Country:US
Practice Address - Phone:304-599-7743
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-30
Last Update Date:2020-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant