Healthcare Provider Details

I. General information

NPI: 1417371691
Provider Name (Legal Business Name): STACEY SALE PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/10/2014
Last Update Date: 12/01/2020
Certification Date: 12/01/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3303 FERN VALLEY RD
LOUISVILLE KY
40213-3529
US

IV. Provider business mailing address

PO BOX 950248
LOUISVILLE KY
40295-0248
US

V. Phone/Fax

Practice location:
  • Phone: 502-964-4889
  • Fax: 502-964-9976
Mailing address:
  • Phone: 502-489-5730
  • Fax: 502-489-5751

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberTC258
License Number StateKY
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA1884
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: