Provider Demographics
NPI:1285329755
Name:EDO, STACY
Entity type:Individual
Prefix:
First Name:STACY
Middle Name:
Last Name:EDO
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 1:7357 CHERRYDALE DR
Mailing Address - Street 2:
Mailing Address - City:DENHAM SPRINGS
Mailing Address - State:LA
Mailing Address - Zip Code:70706-1956
Mailing Address - Country:US
Mailing Address - Phone:225-277-2022
Mailing Address - Fax:
Practice Address - Street 1:7357 CHERRYDALE DR
Practice Address - Street 2:
Practice Address - City:DENHAM SPRINGS
Practice Address - State:LA
Practice Address - Zip Code:70706-1956
Practice Address - Country:US
Practice Address - Phone:225-277-2022
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-10
Last Update Date:2023-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA342000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes342000000XTransportation ServicesTransportation Network Company