Provider Demographics
NPI:1093546145
Name:STACKHOUSE, SAVANNAH LAVINIA
Entity type:Individual
Prefix:
First Name:SAVANNAH
Middle Name:LAVINIA
Last Name:STACKHOUSE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2125 VALLEYGATE DR STE 102
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28304-3753
Mailing Address - Country:US
Mailing Address - Phone:910-864-0689
Mailing Address - Fax:
Practice Address - Street 1:2125 VALLEYGATE DR STE 102
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28304-3753
Practice Address - Country:US
Practice Address - Phone:910-864-0689
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-12
Last Update Date:2024-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5020623363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily