Basic Information
| Provider Information | |||||||||
| NPI: | 1578959474 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | STACY | ||||||||
| FirstName: | SHEILA | ||||||||
| MiddleName: | |||||||||
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| Credential: | LNHA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1180 OLD JACKSON RD | ||||||||
| Address2: | |||||||||
| City: | FARMINGTON | ||||||||
| State: | MO | ||||||||
| PostalCode: | 636403428 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5737601700 | ||||||||
| FaxNumber: | 5737601224 | ||||||||
| Practice Location | |||||||||
| Address1: | 1180 OLD JACKSON RD | ||||||||
| Address2: | |||||||||
| City: | FARMINGTON | ||||||||
| State: | MO | ||||||||
| PostalCode: | 636403428 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5737601700 | ||||||||
| FaxNumber: | 5737601224 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/08/2015 | ||||||||
| LastUpdateDate: | 04/08/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 376G00000X | 5956 | MO | Y | Nursing Service Related Providers | Nursing Home Administrator |
No ID Information.