Provider Demographics
NPI:1245659226
Name:STACK, COLLEEN MARIE (MD)
Entity type:Individual
Prefix:DR
First Name:COLLEEN
Middle Name:MARIE
Last Name:STACK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 68
Mailing Address - Street 2:
Mailing Address - City:POLLOCKSVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28573-0068
Mailing Address - Country:US
Mailing Address - Phone:252-635-3906
Mailing Address - Fax:252-224-0378
Practice Address - Street 1:137 MEDICAL LN
Practice Address - Street 2:
Practice Address - City:POLLOCKSVILLE
Practice Address - State:NC
Practice Address - Zip Code:28573-8200
Practice Address - Country:US
Practice Address - Phone:252-633-1010
Practice Address - Fax:252-224-3071
Is Sole Proprietor?:No
Enumeration Date:2014-04-07
Last Update Date:2019-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NC2019-013932084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program