Provider Demographics
NPI:1154929545
Name:STACY, AMBER
Entity type:Individual
Prefix:
First Name:AMBER
Middle Name:
Last Name:STACY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:TATEN
Other - Middle Name:LEVI
Other - Last Name:KENNEDY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 1616
Mailing Address - Street 2:
Mailing Address - City:PRINCETON
Mailing Address - State:WV
Mailing Address - Zip Code:24740-1616
Mailing Address - Country:US
Mailing Address - Phone:304-887-5036
Mailing Address - Fax:
Practice Address - Street 1:3057 MAPLE ACRES ROAD
Practice Address - Street 2:
Practice Address - City:BLUEFIELD
Practice Address - State:WV
Practice Address - Zip Code:24801
Practice Address - Country:US
Practice Address - Phone:304-887-5036
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-16
Last Update Date:2020-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV3747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant