Provider Demographics
NPI:1821640749
Name:HART, STACEY LYNNE
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:LYNNE
Last Name:HART
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 1:10830 HARBOR BAY DR
Mailing Address - Street 2:
Mailing Address - City:FISHERS
Mailing Address - State:IN
Mailing Address - Zip Code:46040-9012
Mailing Address - Country:US
Mailing Address - Phone:317-201-4380
Mailing Address - Fax:
Practice Address - Street 1:11591 OLIO RD
Practice Address - Street 2:
Practice Address - City:FISHERS
Practice Address - State:IN
Practice Address - Zip Code:46037-7613
Practice Address - Country:US
Practice Address - Phone:317-585-2702
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-11
Last Update Date:2019-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26016575A1835P2201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835P2201XPharmacy Service ProvidersPharmacistAmbulatory Care