Basic Information
Provider Information | |||||||||
NPI: | 1659378727 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | WORRELL | ||||||||
FirstName: | STACY | ||||||||
MiddleName: | L | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | RNFA | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | HANGEN | ||||||||
OtherFirstName: | STACY | ||||||||
OtherMiddleName: | L | ||||||||
OtherNamePrefix: | MS. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | RNFA | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 710793 | ||||||||
Address2: |   | ||||||||
City: | COLUMBUS | ||||||||
State: | OH | ||||||||
PostalCode: | 432710793 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6142689561 | ||||||||
FaxNumber: | 6142687849 | ||||||||
Practice Location | |||||||||
Address1: | 3555 OLENTANGY RIVER RD | ||||||||
Address2: | SUITE 4000 | ||||||||
City: | COLUMBUS | ||||||||
State: | OH | ||||||||
PostalCode: | 432143912 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6142689561 | ||||||||
FaxNumber: | 6142687849 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/05/2005 | ||||||||
LastUpdateDate: | 07/08/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | X | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 032526 | OH | Y |   | Other Service Providers | Specialist |   | 174400000X | RN-293715 | OH | N |   | Other Service Providers | Specialist |   |
ID Information
ID | Type | State | Issuer | Description | 000000337075 | 01 | OH | ANTHEM PIN | OTHER |