Provider Demographics
NPI:1649830506
Name:STACY, KIMBERLY LYNN (MED SP ED)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:LYNN
Last Name:STACY
Suffix:
Gender:F
Credentials:MED SP ED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 DUNKLE CT
Mailing Address - Street 2:
Mailing Address - City:TANEYTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:21787-2317
Mailing Address - Country:US
Mailing Address - Phone:315-877-6937
Mailing Address - Fax:
Practice Address - Street 1:11 DUNKLE CT
Practice Address - Street 2:
Practice Address - City:TANEYTOWN
Practice Address - State:MD
Practice Address - Zip Code:21787-2317
Practice Address - Country:US
Practice Address - Phone:315-877-6937
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-13
Last Update Date:2019-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD3889222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist