Provider Demographics
NPI:1811279490
Name:PENDRY, STACEY LYLES
Entity type:Individual
Prefix:MRS
First Name:STACEY
Middle Name:LYLES
Last Name:PENDRY
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:STACEY
Other - Middle Name:NICOLE
Other - Last Name:LYLES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:263 OCONEE RIVER CIR
Mailing Address - Street 2:
Mailing Address - City:ATHENS
Mailing Address - State:GA
Mailing Address - Zip Code:30605-4238
Mailing Address - Country:US
Mailing Address - Phone:336-870-1653
Mailing Address - Fax:
Practice Address - Street 1:263 OCONEE RIVER CIR
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:GA
Practice Address - Zip Code:30605-4238
Practice Address - Country:US
Practice Address - Phone:336-870-1653
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-09-09
Last Update Date:2013-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9700235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist