Provider Demographics
NPI:1942892070
Name:CLEMMONS, STACEY LEE
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:LEE
Last Name:CLEMMONS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:412 PHILLIPS ST W
Mailing Address - Street 2:
Mailing Address - City:DOUGLAS
Mailing Address - State:GA
Mailing Address - Zip Code:31533-2537
Mailing Address - Country:US
Mailing Address - Phone:912-292-5088
Mailing Address - Fax:
Practice Address - Street 1:412 PHILLIPS ST W
Practice Address - Street 2:
Practice Address - City:DOUGLAS
Practice Address - State:GA
Practice Address - Zip Code:31533-2537
Practice Address - Country:US
Practice Address - Phone:912-292-5088
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-10
Last Update Date:2021-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor