Provider Demographics
NPI:1427658640
Name:FONDREN, STACEY (ATP)
Entity type:Individual
Prefix:MS
First Name:STACEY
Middle Name:
Last Name:FONDREN
Suffix:
Gender:F
Credentials:ATP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18802 ATASCA SOUTH DR
Mailing Address - Street 2:
Mailing Address - City:HUMBLE
Mailing Address - State:TX
Mailing Address - Zip Code:77346-4813
Mailing Address - Country:US
Mailing Address - Phone:832-319-9980
Mailing Address - Fax:888-873-7414
Practice Address - Street 1:2111 FM 1960 RD E
Practice Address - Street 2:
Practice Address - City:HUMBLE
Practice Address - State:TX
Practice Address - Zip Code:77338-5229
Practice Address - Country:US
Practice Address - Phone:832-445-0956
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-27
Last Update Date:2020-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX85967332BC3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment