Healthcare Provider Details

I. General information

NPI: 1205487139
Provider Name (Legal Business Name): MS. STACEY C SMITH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/23/2019
Last Update Date: 11/27/2023
Certification Date: 04/17/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4166 LINDELL BLVD STE 1B
SAINT LOUIS MO
63108-2923
US

IV. Provider business mailing address

4166 LINDELL BLVD STE 1B
SAINT LOUIS MO
63108-2923
US

V. Phone/Fax

Practice location:
  • Phone: 314-484-7758
  • Fax:
Mailing address:
  • Phone: 314-484-7758
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: