Provider Demographics
NPI:1265457501
Name:DESAMOURS, STACEY NICOLE (MD)
Entity type:Individual
Prefix:
First Name:STACEY
Middle Name:NICOLE
Last Name:DESAMOURS
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 1:3121 PANTHERSVILLE RD
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30034-3830
Mailing Address - Country:US
Mailing Address - Phone:404-270-8186
Mailing Address - Fax:
Practice Address - Street 1:3121 PANTHERSVILLE RD
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30034-3830
Practice Address - Country:US
Practice Address - Phone:404-270-8186
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-13
Last Update Date:2019-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA62786207ZF0201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZF0201XAllopathic & Osteopathic PhysiciansPathologyForensic Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA09642Medicare UPIN