Provider Demographics
NPI:1417795360
Name:DRAKE, STACY LEE
Entity type:Individual
Prefix:
First Name:STACY
Middle Name:LEE
Last Name:DRAKE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:STACY
Other - Middle Name:
Other - Last Name:MCFARLIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:910 W PARK AVE
Mailing Address - Street 2:
Mailing Address - City:NORFOLK
Mailing Address - State:NE
Mailing Address - Zip Code:68701-5044
Mailing Address - Country:US
Mailing Address - Phone:402-379-3622
Mailing Address - Fax:
Practice Address - Street 1:910 W PARK AVE
Practice Address - Street 2:
Practice Address - City:NORFOLK
Practice Address - State:NE
Practice Address - Zip Code:68701-5044
Practice Address - Country:US
Practice Address - Phone:402-379-3622
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-16
Last Update Date:2024-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NECPSS-329175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist