Provider Demographics
NPI:1073084984
Name:ROUMILLAT, STACEY A (PA)
Entity type:Individual
Prefix:
First Name:STACEY
Middle Name:A
Last Name:ROUMILLAT
Suffix:
Gender:
Credentials:PA
Other - Prefix:
Other - First Name:STACEY
Other - Middle Name:
Other - Last Name:WALDRON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:PO BOX 715868
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19171-5868
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:15564 WESTCHESTER COMMONS WAY STE D
Practice Address - Street 2:
Practice Address - City:MIDLOTHIAN
Practice Address - State:VA
Practice Address - Zip Code:23113-7321
Practice Address - Country:US
Practice Address - Phone:804-440-4878
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-17
Last Update Date:2025-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110006581363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant