Healthcare Provider Details

I. General information

NPI: 1255068961
Provider Name (Legal Business Name): STACY BREANN FOOCE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/03/2022
Last Update Date: 08/03/2022
Certification Date: 06/30/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3170 MAPLELEAF DR APT 203
LEXINGTON KY
40509-2613
US

IV. Provider business mailing address

3170 MAPLELEAF DR APT 203
LEXINGTON KY
40509-2613
US

V. Phone/Fax

Practice location:
  • Phone: 740-208-0466
  • Fax:
Mailing address:
  • Phone: 740-208-0466
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License NumberOH3285639
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number201227983
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: