Provider Demographics
NPI:1205423209
Name:COLEMAN, STACEY L
Entity type:Individual
Prefix:
First Name:STACEY
Middle Name:L
Last Name:COLEMAN
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 1:313 CAMBORNE DR
Mailing Address - Street 2:
Mailing Address - City:ENGLEWOOD
Mailing Address - State:OH
Mailing Address - Zip Code:45322-1211
Mailing Address - Country:US
Mailing Address - Phone:937-830-7908
Mailing Address - Fax:
Practice Address - Street 1:313 CAMBORNE DR
Practice Address - Street 2:
Practice Address - City:ENGLEWOOD
Practice Address - State:OH
Practice Address - Zip Code:45322-1211
Practice Address - Country:US
Practice Address - Phone:937-830-7908
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-23
Last Update Date:2020-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0412382Medicaid