Provider Demographics
NPI:1104448281
Name:DARRISAW, STACEY (RN, CCM)
Entity type:Individual
Prefix:
First Name:STACEY
Middle Name:
Last Name:DARRISAW
Suffix:
Gender:F
Credentials:RN, CCM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:49 WESTWOOD WAY
Mailing Address - Street 2:
Mailing Address - City:FORTSON
Mailing Address - State:GA
Mailing Address - Zip Code:31808-6069
Mailing Address - Country:US
Mailing Address - Phone:762-822-1242
Mailing Address - Fax:706-494-4445
Practice Address - Street 1:2020 7TH AVE
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31904-8914
Practice Address - Country:US
Practice Address - Phone:762-822-1242
Practice Address - Fax:706-494-4445
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-12
Last Update Date:2020-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN124631163WC0400X, 171M00000X, 251B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251B00000XAgenciesCase ManagementGroup - Single Specialty
No163WC0400XNursing Service ProvidersRegistered NurseCase Management
No171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Single Specialty