Healthcare Provider Details

I. General information

NPI: 1053843292
Provider Name (Legal Business Name): STACY BLACKWELL MAGGIO SA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/28/2017
Last Update Date: 10/07/2026
Certification Date: 10/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

119 DRIFTWOOD CIR
SLIDELL LA
70458-1455
US

IV. Provider business mailing address

119 DRIFTWOOD CIR
SLIDELL LA
70458-1455
US

V. Phone/Fax

Practice location:
  • Phone: 985-768-9980
  • Fax:
Mailing address:
  • Phone: 985-768-9980
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: