Provider Demographics
NPI:1861373953
Name:BOOTH, STACY LYNETTE (MA)
Entity type:Individual
Prefix:
First Name:STACY
Middle Name:LYNETTE
Last Name:BOOTH
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:50 W PARK AVE
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43222-1342
Mailing Address - Country:US
Mailing Address - Phone:614-505-3126
Mailing Address - Fax:614-431-4601
Practice Address - Street 1:50 W PARK AVE
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43222-1342
Practice Address - Country:US
Practice Address - Phone:614-505-3126
Practice Address - Fax:614-431-4601
Is Sole Proprietor?:Yes
Enumeration Date:2025-09-08
Last Update Date:2025-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center