Healthcare Provider Details

I. General information

NPI: 1326081969
Provider Name (Legal Business Name): KATHRYN E STACK MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/13/2006
Last Update Date: 12/23/2021
Certification Date: 12/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15 WOOD CREST DR
OLD LYME CT
06371-2840
US

IV. Provider business mailing address

15 WOOD CREST DR
OLD LYME CT
06371-2840
US

V. Phone/Fax

Practice location:
  • Phone: 404-932-9109
  • Fax:
Mailing address:
  • Phone: 404-932-9109
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number57186
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: