Provider Demographics
NPI:1154145878
Name:MALLETT-TROUTMAN, STACY
Entity type:Individual
Prefix:
First Name:STACY
Middle Name:
Last Name:MALLETT-TROUTMAN
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 1:21851 KENNISON AVE
Mailing Address - Street 2:
Mailing Address - City:EUCLID
Mailing Address - State:OH
Mailing Address - Zip Code:44123-1914
Mailing Address - Country:US
Mailing Address - Phone:216-474-3057
Mailing Address - Fax:
Practice Address - Street 1:19609 SHELTON DR
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44110-2741
Practice Address - Country:US
Practice Address - Phone:216-474-3057
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-11-09
Last Update Date:2024-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH175379164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse