Provider Demographics
NPI:1902301468
Name:TWIGG, STACEY
Entity type:Individual
Prefix:
First Name:STACEY
Middle Name:
Last Name:TWIGG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:STACEY
Other - Middle Name:
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4995 BRADENTON AVE STE 130
Mailing Address - Street 2:
Mailing Address - City:DUBLIN
Mailing Address - State:OH
Mailing Address - Zip Code:43017-3551
Mailing Address - Country:US
Mailing Address - Phone:614-580-6917
Mailing Address - Fax:
Practice Address - Street 1:4995 BRADENTON AVE STE 130
Practice Address - Street 2:
Practice Address - City:DUBLIN
Practice Address - State:OH
Practice Address - Zip Code:43017-3551
Practice Address - Country:US
Practice Address - Phone:614-580-6917
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-27
Last Update Date:2024-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHS.1450509104100000X
OH472924163W00000X
OHAPRN.CNP.0032697363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
No163W00000XNursing Service ProvidersRegistered Nurse