Provider Demographics
NPI:1962029330
Name:STACKHOUSE, TAVONIA
Entity type:Individual
Prefix:
First Name:TAVONIA
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 1:4110 HUNTERS HILL CIR
Mailing Address - Street 2:
Mailing Address - City:RANDALLSTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:21133-5323
Mailing Address - Country:US
Mailing Address - Phone:443-941-6063
Mailing Address - Fax:
Practice Address - Street 1:713 W PRATT ST
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21201-1023
Practice Address - Country:US
Practice Address - Phone:443-941-6063
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-01
Last Update Date:2020-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD374U00000X, 374U00000X
MDR4449R251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Yes374U00000XNursing Service Related ProvidersHome Health Aide