Healthcare Provider Details

I. General information

NPI: 1124360185
Provider Name (Legal Business Name): STACEY MICHELLE FOLEY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/17/2013
Last Update Date: 03/17/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 AUTUMN CREST TRL
ROCK SPRING GA
30739-2095
US

IV. Provider business mailing address

100 AUTUMN CREST TRL
ROCK SPRING GA
30739-2095
US

V. Phone/Fax

Practice location:
  • Phone: 706-375-1117
  • Fax:
Mailing address:
  • Phone: 706-375-1117
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number1930
License Number StateTN
# 2
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number001273
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: