Healthcare Provider Details

I. General information

NPI: 1285596866
Provider Name (Legal Business Name): STACY-LEE MELEISIA BUCHANAN-BROMLEY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/02/2025
Last Update Date: 12/02/2025
Certification Date: 12/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

113 W RIVER CANE RUN
PERRY GA
31069-9470
US

IV. Provider business mailing address

113 W RIVER CANE RUN
PERRY GA
31069-9470
US

V. Phone/Fax

Practice location:
  • Phone: 470-439-1396
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number287824
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: