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NPI Code Detail

MEDICARE: STACEY DARRISAW RN, CCM

MEDICARE: STACEY DARRISAW RN, CCM
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1163WC0400XCase Management Registered NurseRN124631GA
2171M00000XCase Manager/Care CoordinatorRN124631GA
3251B00000XCase Management AgencyRN124631GA

General Provider Information

NPI Number : 1104448281
Entity Type Code : Individual
Provider Name (Legal Business Name) : STACEY DARRISAW RN, CCM
Provider Business Mailing Address
First Line : 49 WESTWOOD WAY
Second Line :
City : FORTSON
State : GA
Zip : 31808-6069
Country : US
Telephone Number : 762-822-1242
Fax Number : 706-494-4445
Provider Business Practice Location Address
First Line : 2020 7TH AVE
Second Line :
City : COLUMBUS
State : GA
Zip : 31904-8914
Country : US
Telephone Number : 762-822-1242
Fax Number : 706-494-4445
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 05/12/2020
Last Update Date : 05/12/2020

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