Healthcare Provider Details

I. General information

NPI: 1770629099
Provider Name (Legal Business Name): STACEY STOKES ROUSSELL MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/30/2007
Last Update Date: 05/08/2024
Certification Date: 05/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

439 COUNTRY LN
LOUISVILLE KY
40207-1803
US

IV. Provider business mailing address

439 COUNTRY LN
LOUISVILLE KY
40207-1803
US

V. Phone/Fax

Practice location:
  • Phone: 502-939-5378
  • Fax:
Mailing address:
  • Phone: 502-939-5378
  • Fax: 502-272-5337

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2080A0000X
TaxonomyPediatric Adolescent Medicine Physician
License Number35005
License Number StateKY
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number35005
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: