Provider Demographics
NPI:1649032087
Name:HORNE, STACEY D
Entity type:Individual
Prefix:
First Name:STACEY
Middle Name:D
Last Name:HORNE
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 1:3795 WILLOW RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:DOUGLASVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30135-2790
Mailing Address - Country:US
Mailing Address - Phone:478-370-8949
Mailing Address - Fax:
Practice Address - Street 1:3795 WILLOW RIDGE RD
Practice Address - Street 2:
Practice Address - City:DOUGLASVILLE
Practice Address - State:GA
Practice Address - Zip Code:30135-2790
Practice Address - Country:US
Practice Address - Phone:478-370-8949
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-30
Last Update Date:2024-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor