Healthcare Provider Details

I. General information

NPI: 1639187941
Provider Name (Legal Business Name): STELLA R. STALEY M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/03/2006
Last Update Date: 09/26/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 S 1ST ST
LOUISVILLE KY
40202-1416
US

IV. Provider business mailing address

143 AISHLINS CT
RICHMOND KY
40475-7975
US

V. Phone/Fax

Practice location:
  • Phone: 502-574-2273
  • Fax: 502-574-7853
Mailing address:
  • Phone: 859-396-4874
  • Fax: 502-574-7853

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number24651
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: