Provider Demographics
NPI:1821781972
Name:BURWELL, STACY
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:
Last Name:BURWELL
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:PO BOX 214
Mailing Address - Street 2:
Mailing Address - City:LEIVASY
Mailing Address - State:WV
Mailing Address - Zip Code:26676-0214
Mailing Address - Country:US
Mailing Address - Phone:304-618-1336
Mailing Address - Fax:
Practice Address - Street 1:1314 HOMINY FALLS
Practice Address - Street 2:
Practice Address - City:LEIVASY
Practice Address - State:WV
Practice Address - Zip Code:26676
Practice Address - Country:US
Practice Address - Phone:304-618-1336
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-02
Last Update Date:2023-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker