Provider Demographics
NPI:1821378027
Name:FORD, STACY LADEANE (WHNP)
Entity Type:Individual
Prefix:MRS
First Name:STACY
Middle Name:LADEANE
Last Name:FORD
Suffix:
Gender:F
Credentials:WHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 S BOYLAN AVE
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27603-1802
Mailing Address - Country:US
Mailing Address - Phone:919-833-7526
Mailing Address - Fax:919-832-9061
Practice Address - Street 1:2712 MIDDLEBURG DR
Practice Address - Street 2:SUITE 107
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29204-2415
Practice Address - Country:US
Practice Address - Phone:803-256-4908
Practice Address - Fax:803-256-4900
Is Sole Proprietor?:No
Enumeration Date:2011-08-19
Last Update Date:2015-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAFOR104269443363LX0001X
GARN102954363L00000X
SC4036363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
No363LX0001XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerObstetrics & Gynecology
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner