Provider Demographics
NPI:1164865465
Name:DEVOL, STACY LEA (CCNS)
Entity type:Individual
Prefix:
First Name:STACY
Middle Name:LEA
Last Name:DEVOL
Suffix:
Gender:F
Credentials:CCNS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:416 COLEGATE DR BLDG 3
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:OH
Mailing Address - Zip Code:45750-9549
Mailing Address - Country:US
Mailing Address - Phone:740-568-4814
Mailing Address - Fax:740-374-3165
Practice Address - Street 1:400 MATTHEW ST STE 401
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:OH
Practice Address - Zip Code:45750-1656
Practice Address - Country:US
Practice Address - Phone:740-374-2252
Practice Address - Fax:740-374-4974
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-17
Last Update Date:2021-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCOA.13383-NS364SC0200X
OHAPRN.CNS.13383364SA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SA2100XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistAcute Care
No364SC0200XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0101019Medicaid
WV3810027353Medicaid
OH0101019Medicaid
OHP01472202OtherRAILROAD - MHCPI