Basic Information
| Provider Information | |||||||||
| NPI: | 1972834182 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FLETCHER | ||||||||
| FirstName: | STACEY | ||||||||
| MiddleName: | EVANS | ||||||||
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| Credential: | DPT | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | EVANS | ||||||||
| OtherFirstName: | STACEY | ||||||||
| OtherMiddleName: | LYNN | ||||||||
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| OtherCredential: | DPT | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 981 HIGH HOUSE RD STE 100 | ||||||||
| Address2: | |||||||||
| City: | CARY | ||||||||
| State: | NC | ||||||||
| PostalCode: | 275133510 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9193880111 | ||||||||
| FaxNumber: | 9193888668 | ||||||||
| Practice Location | |||||||||
| Address1: | 3150 ROGERS RD STE 216 | ||||||||
| Address2: | |||||||||
| City: | WAKE FOREST | ||||||||
| State: | NC | ||||||||
| PostalCode: | 275877068 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9192298363 | ||||||||
| FaxNumber: | 9192298356 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/28/2010 | ||||||||
| LastUpdateDate: | 11/02/2020 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 11/02/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 23119 | MD | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | P18328 | NC | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.