Healthcare Provider Details

I. General information

NPI: 1700294006
Provider Name (Legal Business Name): STACEY MOMO NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/30/2014
Last Update Date: 09/15/2026
Certification Date: 09/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2300 PENNSYLVANIA AVE STE 1A
WILMINGTON DE
19806-1333
US

IV. Provider business mailing address

2300 PENNSYLVANIA AVE STE 1A
WILMINGTON DE
19806-1333
US

V. Phone/Fax

Practice location:
  • Phone: 302-830-8636
  • Fax:
Mailing address:
  • Phone: 302-830-8686
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberLG-0013898
License Number StateDE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: