Healthcare Provider Details

I. General information

NPI: 1073504965
Provider Name (Legal Business Name): STACY LYNN SHOUP MS, CGC
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 10/31/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4755 OGLETOWN-STANTON ROAD RM 1988
NEWARK DE
19718-0001
US

IV. Provider business mailing address

104 YARDLEY PL
HOCKESSIN DE
19707-8917
US

V. Phone/Fax

Practice location:
  • Phone: 302-733-3072
  • Fax: 302-733-3074
Mailing address:
  • Phone: 302-235-2472
  • Fax: 302-733-3074

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code170300000X
TaxonomyGenetic Counselor (M.S.)
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: