Provider Demographics
NPI:1780476754
Name:NELSON, STACY SMITH
Entity type:Individual
Prefix:MS
First Name:STACY
Middle Name:SMITH
Last Name:NELSON
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:PO BOX 366
Mailing Address - Street 2:
Mailing Address - City:IRMO
Mailing Address - State:SC
Mailing Address - Zip Code:29063-0366
Mailing Address - Country:US
Mailing Address - Phone:518-491-0012
Mailing Address - Fax:
Practice Address - Street 1:1509 HAVILAND CIR
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29210-4051
Practice Address - Country:US
Practice Address - Phone:518-491-0012
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-05-19
Last Update Date:2025-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor
No174400000XOther Service ProvidersSpecialist
No347C00000XTransportation ServicesPrivate Vehicle