Provider Demographics
NPI:1922678549
Name:WILSON, STACEY (PHDHP)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:PHDHP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8071 MEADOW GAP RD
Mailing Address - Street 2:
Mailing Address - City:THREE SPRINGS
Mailing Address - State:PA
Mailing Address - Zip Code:17264-8623
Mailing Address - Country:US
Mailing Address - Phone:814-251-2042
Mailing Address - Fax:
Practice Address - Street 1:8071 MEADOW GAP RD
Practice Address - Street 2:
Practice Address - City:THREE SPRINGS
Practice Address - State:PA
Practice Address - Zip Code:17264-8623
Practice Address - Country:US
Practice Address - Phone:814-251-2042
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-26
Last Update Date:2021-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist