Basic Information
| Provider Information | |||||||||
| NPI: | 1912986852 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DEVINE | ||||||||
| FirstName: | STACEY | ||||||||
| MiddleName: | E | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 60447 | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282600447 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7043849113 | ||||||||
| FaxNumber: | 7043160508 | ||||||||
| Practice Location | |||||||||
| Address1: | 19485 OLD JETTON RD | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | CORNELIUS | ||||||||
| State: | NC | ||||||||
| PostalCode: | 280316582 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7043841775 | ||||||||
| FaxNumber: | 7043841776 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/10/2006 | ||||||||
| LastUpdateDate: | 03/18/2015 | ||||||||
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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 | 207Q00000X | 200401383 | NC | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 5900010 | 05 | NC | MEDICAID |