Provider Demographics
NPI:1902524754
Name:SMITH, STACY (MDIV, EDD)
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:MDIV, EDD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1211 UNION AVE FL 7
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38104-6638
Mailing Address - Country:US
Mailing Address - Phone:202-487-0818
Mailing Address - Fax:
Practice Address - Street 1:1211 UNION AVE FL 7
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38104-6638
Practice Address - Country:US
Practice Address - Phone:202-487-0818
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-18
Last Update Date:2022-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374K00000XNursing Service Related ProvidersReligious Nonmedical Practitioner