Provider Demographics
NPI:1356155444
Name:MACKAY-MERCER, STACI (CO)
Entity type:Individual
Prefix:
First Name:STACI
Middle Name:
Last Name:MACKAY-MERCER
Suffix:
Gender:F
Credentials:CO
Other - Prefix:
Other - First Name:STACI
Other - Middle Name:
Other - Last Name:MACKAY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CO
Mailing Address - Street 1:129 MIRRAMONT LAKE DR
Mailing Address - Street 2:
Mailing Address - City:WOODSTOCK
Mailing Address - State:GA
Mailing Address - Zip Code:30189-8215
Mailing Address - Country:US
Mailing Address - Phone:770-800-2030
Mailing Address - Fax:
Practice Address - Street 1:129 MIRRAMONT LAKE DR
Practice Address - Street 2:
Practice Address - City:WOODSTOCK
Practice Address - State:GA
Practice Address - Zip Code:30189-8215
Practice Address - Country:US
Practice Address - Phone:770-401-1408
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-02-06
Last Update Date:2025-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAC062222Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes222Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotistGroup - Single Specialty