Basic Information
| Provider Information | |||||||||
| NPI: | 1164865465 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DEVOL | ||||||||
| FirstName: | STACY | ||||||||
| MiddleName: | LEA | ||||||||
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| Credential: | CCNS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 416 COLEGATE DR BLDG 3 | ||||||||
| Address2: | |||||||||
| City: | MARIETTA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 457509549 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7405684814 | ||||||||
| FaxNumber: | 7403743165 | ||||||||
| Practice Location | |||||||||
| Address1: | 400 MATTHEW ST STE 401 | ||||||||
| Address2: | |||||||||
| City: | MARIETTA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 457501656 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7403742252 | ||||||||
| FaxNumber: | 7403744974 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/17/2013 | ||||||||
| LastUpdateDate: | 07/16/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 07/16/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 364SC0200X | COA.13383-NS | OH | N | Physician Assistants & Advanced Practice Nursing Providers | Clinical Nurse Specialist | Critical Care Medicine | 364SA2100X | APRN.CNS.13383 | OH | Y | Physician Assistants & Advanced Practice Nursing Providers | Clinical Nurse Specialist | Acute Care |
ID Information
| ID | Type | State | Issuer | Description | 0101019 | 05 | OH | MEDICAID | 3810027353 | 05 | WV | MEDICAID |