Provider Demographics
NPI:1962795138
Name:CREEDEN, STACIE
Entity type:Individual
Prefix:
First Name:STACIE
Middle Name:
Last Name:CREEDEN
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 1:13901 HEATHCOTE BLVD
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:20155
Mailing Address - Country:US
Mailing Address - Phone:703-754-7166
Mailing Address - Fax:703-754-0428
Practice Address - Street 1:13901 HEATHCOTE BLVD
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:VA
Practice Address - Zip Code:20155-1562
Practice Address - Country:US
Practice Address - Phone:703-754-7166
Practice Address - Fax:703-754-0428
Is Sole Proprietor?:No
Enumeration Date:2011-05-22
Last Update Date:2015-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0202009925183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist