Provider Demographics
NPI:1306687298
Name:STACKHOUSE, ANNIE
Entity type:Individual
Prefix:
First Name:ANNIE
Middle Name:
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 1:2920 EASTOVER NORTH DR
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28312-6707
Mailing Address - Country:US
Mailing Address - Phone:910-261-3633
Mailing Address - Fax:
Practice Address - Street 1:2920 EASTOVER NORTH DR
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28312-6707
Practice Address - Country:US
Practice Address - Phone:910-261-3633
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-04
Last Update Date:2024-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC206304163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse