Healthcare Provider Details

I. General information

NPI: 1134856545
Provider Name (Legal Business Name): SABRINA STACKHOUSE MT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/04/2022
Last Update Date: 04/01/2026
Certification Date: 04/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5164 E 81ST AVE
MERRILLVILLE IN
46410-5852
US

IV. Provider business mailing address

5164 E 81ST AVE
MERRILLVILLE IN
46410-5852
US

V. Phone/Fax

Practice location:
  • Phone: 219-294-9411
  • Fax:
Mailing address:
  • Phone: 219-294-9411
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code247200000X
TaxonomyOther Technician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code246RP1900X
TaxonomyPhlebotomy Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: