Provider Demographics
NPI:1013281971
Name:TILLETT, STACEY MICHELLE
Entity Type:Individual
Prefix:MRS
First Name:STACEY
Middle Name:MICHELLE
Last Name:TILLETT
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 1:4012 POOR RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:KITTY HAWK
Mailing Address - State:NC
Mailing Address - Zip Code:27949-4334
Mailing Address - Country:US
Mailing Address - Phone:252-493-2595
Mailing Address - Fax:
Practice Address - Street 1:4012 POOR RIDGE RD
Practice Address - Street 2:
Practice Address - City:KITTY HAWK
Practice Address - State:NC
Practice Address - Zip Code:27949-4334
Practice Address - Country:US
Practice Address - Phone:252-493-2595
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-23
Last Update Date:2013-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC390200000X
NC10299235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program