Healthcare Provider Details

I. General information

NPI: 1871988337
Provider Name (Legal Business Name): STACEY JOY HAYNES MCCLINTICK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/01/2015
Last Update Date: 07/18/2024
Certification Date: 07/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2480 LLEWELLYN AVE
FT. MEADE MD
20755
US

IV. Provider business mailing address

1061 HARMON AVE
FORT STEWART GA
31314-5641
US

V. Phone/Fax

Practice location:
  • Phone: 912-349-9945
  • Fax:
Mailing address:
  • Phone: 912-435-6965
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number0101261652
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: