Provider Demographics
NPI:1003514696
Name:HOGAN, STACIE MARIE (BSN, IBCLC)
Entity type:Individual
Prefix:MRS
First Name:STACIE
Middle Name:MARIE
Last Name:HOGAN
Suffix:
Gender:F
Credentials:BSN, IBCLC
Other - Prefix:MRS
Other - First Name:STACIE
Other - Middle Name:MARIE
Other - Last Name:MARGO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:5416 SETTER RD
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24012-8548
Mailing Address - Country:US
Mailing Address - Phone:540-915-8400
Mailing Address - Fax:
Practice Address - Street 1:3142 BRAMBLETON AVE
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24018-3727
Practice Address - Country:US
Practice Address - Phone:540-200-8662
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-22
Last Update Date:2023-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VAL-309498163WL0100X
VAL-309398163WL0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WL0100XNursing Service ProvidersRegistered NurseLactation Consultant