Provider Demographics
NPI:1851746010
Name:STALLWORTH, PATTY (CEO)
Entity Type:Individual
Prefix:
First Name:PATTY
Middle Name:
Last Name:STALLWORTH
Suffix:
Gender:F
Credentials:CEO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:273 AZALEA RD BLDG 1
Mailing Address - Street 2:SUITE 100
Mailing Address - City:MOBILE
Mailing Address - State:AL
Mailing Address - Zip Code:36609-1970
Mailing Address - Country:US
Mailing Address - Phone:251-607-6327
Mailing Address - Fax:
Practice Address - Street 1:273 AZALEA RD BLDG 1
Practice Address - Street 2:SUITE 100
Practice Address - City:MOBILE
Practice Address - State:AL
Practice Address - Zip Code:36609-1970
Practice Address - Country:US
Practice Address - Phone:251-607-6327
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-25
Last Update Date:2016-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL347C00000X171000000X, 347C00000X
AL374U00000X374U00000X
AL347C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
No171000000XOther Service ProvidersMilitary Health Care Provider
No347C00000XTransportation ServicesPrivate Vehicle
Provider Identifiers
StateIdentifier IDID TypeIssuer
1326069964OtherVETERANS HOMEBOUND SERVICES
1679654966OtherVETERANS HOMEBOUND SERVICES